In 2008, the World Health Organization (WHO) developed guidelines to standardize the process of wheelchair service delivery. The eight steps include referral and appointment, patient assessment, prescription for the wheelchair, funding and purchasing, device installation/preparation, device fitting, patient instruction/training, and follow-up maintenance and repairs. The main features of a wheelchair include a seat, wheels, tires, casters, leg rests, wheel locks, hand rims, armrests, and cushions. Additional items may include anti-tippers, lap trays, or seatbelts if needed (NCBI, 2021).
A comprehensive wheelchair evaluation includes a complete history and physical examination, cognitive and communication skills assessment, and consideration of premorbid functioning and co-morbidities. The patient's motor and sensory function, muscle strength and tone, vision, hearing, postural control, and range of motion will be assessed as significant deficits in any of those areas could make the operation of the assistive device unsafe. Consideration of functional impairments, ADLs, IADLs, occupational roles, social engagement, transportation needs, insurance funding, and the home or living environment must also be considered during the wheelchair assessment (NCBI, 2021).
A standard wheelchair is 24 inches in diameter with rear wheels, 8-inch front casters, weighs 40 to 65 pounds, and is designed to be operated using the hand rims on the wheels. There are many other types of wheelchairs available, including lightweight, ultra-lightweight, one-arm drive, standard heavy-duty, and motorized wheelchairs (NCBI, 2021).
The following measurements must be taken to ensure an appropriate fit for a wheelchair:
- seat width, depth, and height
- patient hip, trunk, and shoulder-width
- patient shoulder and axillae height
- wheelchair leg, arm, and back height
- wheelchair width, height, and size
- knee to seat and knee to heel length
- seat to the back, seat to the lower leg, and lower leg support to foot angle
- fingertip to axle length to allow for self-propulsion (NCBI, 2021)
The wheelchair seating system should provide sufficient support when the patient is seated. It should allow for normal anatomical alignment while accommodating fixed postural asymmetries. There should be adequate stability when sitting in a neutral position with evenly distributed pressure. The wheelchair should promote function and the successful completion of ADLs and IADLs. The seating system will include a seat and back. It may also include lateral trunk supports, head supports, and pelvic belt supports. The seating system will either be placed on a manual or power wheelchair base. An efficient seating system should support the trunk and provide stability.
For this reason, the seat and back should be firm. The primary and secondary supports will minimize pressure at the bony prominences of the pelvis and sacrum. Various cushions are available, including foam, gel, contoured, saddle, wedge, antithrust, and pommel (NCBI, 2021).
Additional considerations for wheelchair fitting include:
- There should be 1 inch of space between the patient's thighs and armrests.
- The pelvis should be positioned with a slight anterior tilt to distribute body weight evenly.
- The armrests should allow 30 degrees of shoulder flexion with 60 degrees of elbow flexion.
- The foot should be about 2 inches from the ground and mounted far enough from the casters to avoid falls or lower extremity injury but not too far as that could place extra tension on the hamstrings (NCBI, 2021).