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Wheelchair service monitoring

Wheelchair Service Delivery

Part three of the provision of manual wheelchairs in  less resourced settings. Published with permission of the World Health Organization. This chapter covers the structural guidelines for wheelchair service delivery systems that provide and improve access to wheelchairs. The need to provide wheelchairs together with these related services is essential. Careful planning, management and sound strategies for wheelchair provision, as well as user instruction and care are needed to facilitate the important link between the user and the wheelchair.

We cover all stages of the service delivery process, from referral to assessment and prescription, funding, ordering, product preparation, fitting, user training and maintenance. Including discussion of the roles of those involved in wheelchair service delivery, from manufacturers and clinicians, to technical and training personnel. Recommendations are made on monitoring, how to obtain feedback from wheelchair users, and evaluating and analyzing information on wheelchair service delivery.

  • Manual wheelchair sourcing supply, manufacture, supply suggest strategies for introducing wheelchair service delivery.
  • Describe basic wheelchair service delivery.
  • Provide practice guidelines.
  • Suggest roles for the personnel involved.
  • Make recommendations on monitoring and evaluation.

Testimonial from a user in Romania, Ciprian is 25 years old and lives in Sfantu Gheorghe, Romania. Three years ago he became paraplegic after falling from a roof while at work and lost any hope that he would ever have a normal and active life again. Sometime after the accident, however, he heard about a local nongovernmental organization that provided support for users. Through the wheelchair service run by the organization, Ciprian received an active-style manual wheelchair that was fitted for him. He was also invited to participate in a peer group training camp. 

Once I got there I realized that I could have an independent life. Through the peer group training, I learnt to use my wheelchair very well. I also had the chance to talk with other users involved in the programme. At the end of the camp, I was asked if I would like to become a peer group trainer. Of course, I was very happy about this chance that had just been offered to me. In January 2006, I started my work as an instructor.
 
Through my wheelchair, and peer training, I have recovered the independence I thought I had lost because of the injury. In addition to my peer group training work, I take part in various competitions and sports activities for people in wheelchairs. Working with people with disabilities makes me feel that I am useful again and that I finally have a normal life after I had had such a hard time overcoming the health problems brought about by the injury. — Cipran of Romania

The purpose of these manual wheelchair service delivery guidelines is to improve the way in which users receive wheelchairs and to ensure that the wheelchairs are appropriate. The implementation of the recommendations in this chapter aim to see more success stories like Cipran come true. We begin with these basic principles: 

  • A greater number of wheelchair services.
  • Better knowledge of wheelchair service delivery among health care and social service workers.
  • Better service quality delivered by existing wheelchair services.
  • A greater number of appropriate wheelchairs provided to users.
  • A greater number of users able to make informed decisions about the most appropriate wheelchair for them.
  • A greater number of users and caregivers receiving training in the use and maintenance of wheelchairs and on how to stay healthy in a wheelchair.
  • Links between users and producers, leading to producers obtaining feedback on the wheelchairs they produce.
  • Coordinate efforts in the planning, implementation and support of wheelchair service delivery among stakeholders.

In the rehabilitation of a person with a spinal cord injury the provision of an appropriate wheelchair is critical. It is important that the wheelchair fits correctly and meets the user’s physical, functional and environmental needs as much as possible. This requires an approach that responds to individual needs. An effective way of meeting the individual needs of users is to promote the provision of wheelchairs through wheelchair services.

Wheelchair services provide the framework for assessing individual user needs, assist in selecting an appropriate wheelchair, train users and caregivers, and provide ongoing support and referral to other services where appropriate. In addition providers of wheelchair services will play a role in the following.

  • Awareness: disseminating basic information about the needs for and benefits of using a wheelchair (this can also be done by personnel involved in community-based rehabilitation, health and education programmes as well as by disabled people’s organizations) and convincing policy-makers about the benefits of investing in wheelchair provision rather than leaving people with disabilities to survive on charity.
  • Identification: using a screening tool to identify those who can benefit from available services.
  • Awareness of referral networks and suppliers: promoting the role of wheelchair services, including participation in activities aimed at educating referral networks and raising the awareness of suppliers and funding agencies regarding the role and importance of wheelchair services. 
  • Sustainability: developing sustainable financial solutions for the continuing provision of mobility equipment through wheelchair services.
  • Training: providing or supporting the training of wheelchair service personnel.
  • Standards: raising wheelchair standards within the country or region through being aware of current wheelchair availability and advocating for improvements in and a greater variety of wheelchair products.
  • Accessibility: supporting or facilitating the adaptation of homes (including toilets, furniture and fittings) and public buildings and places, and lobbying for a barrier-free environment.

Wheelchair Service Delivery Strategies

Wheelchair service delivery requires careful planning and management of resources. There are a number of strategies that can be employed to initiate or further develop wheelchair services. Provide wheelchairs together with services. There are different methods of wheelchair supply to meet the range of contexts in which users live. Whatever the method or structure chosen, it is important to at least deliver the essential wheelchair services.

Utilize existing personnel. It is not necessary to create a new profession to provide wheelchair services. With additional training, many health and rehabilitation personnel would be able to take on the duties required for basic wheelchair service delivery. For example, community health care workers, community-based rehabilitation workers, nurses, physiotherapists, occupational therapists, orthopedists and prosthetists could be trained to fulfil the clinical role in wheelchair services. Likewise, with additional training, skilled craftspeople, mechanics and orthotic and prosthetic technicians could fulfil the technical role.

Meet the needs of users at community level. Some aspects of wheelchair provision can be carried out in the community, through a network of community-based organizations (for example rehabilitation and health programmes) supported by a local wheelchair service delivery centre. The personnel of the community-based programmes could be trained by wheelchair service personnel in basic service delivery. This system of service delivery would best suit users who require a basic wheelchair, without modifications, postural support or pressure management care.

Users with more complex needs are likely to require the skills of personnel with greater training than can be provided to all community-level personnel. This need can be addressed by outreach services coordinated by the wheelchair service centre. If outreach services are not developed, these users would need to travel to the wheelchair service centre. However, once provided with an appropriate wheelchair, they may be supported by community-based personnel.

A wheelchair service can make use of the skills, technologies and capacities of local industries. For example, bicycle repair shops can also repair wheelchairs, and tubular furniture makers have the basic skills and knowledge to build wheelchairs.

Two Tier Wheelchair Service Approach

This shows a possible model of linking a wheelchair service centre with a number of community-based wheelchair services. To provide adequate support to the community-based centres, it may be necessary to first develop the wheelchair service centre. Alternatively, a collaborative effort between existing community based centres could work towards the development of the wheelchair service centre. In either case, the development process should be based on a needs assessment and other aspects of the local context.

The Wheelchair Service Delivery Centre

Characteristics: Centre-based. Facilities (possibly shared with existing health or rehabilitation services): clinical and user training facilities, workshop facilities. Staff: dedicated wheelchair service centre personnel trained to meet the needs of all users.

Key functions: Wheelchair service delivery for all users. Community outreach linking with community based wheelchair services and referral networks. Training, support and supervision of community based wheelchair services and personnel. Education of referral sources. Linking with education, employment and other key development sectors.

Community Based Wheelchair Services

Characteristics: Centre-based, with some wheelchair service delivery carried out entirely in the community. Facilities (shared with other community health and rehabilitation programmes): access to clinic, user training facilities, basic workshop facilities. Staff: community health and rehabilitation workers trained in basic wheelchair service delivery, supervised and supported by wheelchair service centre personnel.

Key functions: Wheelchair service delivery for users requiring basic wheelchairs without custom modifications or postural support components. Identification of users with complex needs, and referral to wheelchair service centre. Where appropriate, support of users with more complex needs for follow-up, maintenance and repair in the community. Support of accessibility, including adaptation of user’s environment such as wider doors and ramps.

Intergrating wheelchair service delivery with other departments can be established within existing rehabilitation services. Such services are already likely to have users accessing the service for health or rehabilitation needs. They would therefore already have much of the infrastructure required. Examples of rehabilitation services well suited to the integration of a wheelchair service include prosthetics and orthotics services and spinal injury centres.

Wheelchair service delivery could play a dual role, providing wheelchairs directly to users and supporting basic services in the community through partnerships with community-level programmes and organizations.

Stakeholders and Resources

Stakeholders directly involved in the planning, implementation and participation in service delivery include: 

  • Users and their families or caregivers.
  • Government authorities, including ministries responsible for health, social welfare and education and other relevant departments and local authorities.
  • Existing health and rehabilitation services (including referral networks) managed by governmental, private, nongovernmental, international nongovernmental or disabled people’s organizations.
  • Supporting organizations providing technical input or funding.
  • Rehabilitation personnel and their organizations.
  • Wheelchair service personnel.

The resources required to implement the recommendations include:

  • A reliable supply of wheelchairs that meet agreed standards.
  • Access to different types and sizes of wheelchair to meet the varied needs of individual users.
  • Personnel with training in wheelchair service delivery.
  • Facilities (which may be shared with existing rehabilitation or health services): clinical facilities providing sufficent space for assessment basic user training and storage of wheelchairs and workshop facilities particularly where modifications to wheelchairs are offered or support is provided.
  • Materials for wheelchair modifications and custom components.
  • Funding to support wheelchair service delivery (products and services).

Wheelchair Service Delivery Network

In Papua New Guinea, an estimated 50 000 people need a wheelchair. Throughout 2003 and 2004, governmental health and rehabilitation organizations and national and international nongovernmental organizations developed a strategy for wheelchair provision. As a result, a pilot wheelchair service network, closely linked to the existing health and rehabilitation services, was set up.

The wheelchair service delivery network consists of a “regional wheelchair service” supporting four “satellite wheelchair services”. The regional service is based at the National Orthotics and Prosthetics Service in Lae. At the regional service, technical personnel from the National Orthotics and Prosthetics Service team and physical therapy personnel from Lae’s Angau Hospital together carry out assessment, prescription, fitting, user training and follow-up. The National Orthotics and Prosthetics Service provides repair services for users. This mixture of clinical and technical facilities has made the setting up of the wheelchair service relatively easy, and the recent provision of dedicated premises for the service has given it a stronger identity.

Two of the satellite services are based in local hospitals, one in a local prosthetic unit and one in a local community based rehabilitation service. The community-based rehabilitation link with each service is strong. The community based rehabilitation networks provide excellent referral, and the personnel work with hospital-based personnel to provide users with a wheelchair.

Training in basic wheelchair service delivery for all of the clinical and technical personnel involved in the service network was provided over two weeks by the international nongovernmental organization Motivation. Further support for both clinical and technical personnel for one year was provided by a volunteer physiotherapist.

The network has the capacity to provide 25 wheelchairs per month. This is still not sufficient to meet the needs in Papua New Guinea. However, through the success of this pilot exercise in using existing services and personnel, much has been learnt about the role of wheelchair services. In future, all stakeholders are keen to see the establishment of more satellite services, as well as an increase in the capacity of the network to meet the needs of users with more complex needs.

Steps in Wheelchair Service Delivery

Wheelchair services are commonly delivered in a sequence of steps. A summary of eight (8) key steps typically involved in wheelchair service delivery are as follows:

  • Referral and appointment The system of referral will depend on existing services in the country. Users may self-refer or be referred through networks made up of governmental or nongovernmental health and rehabilitation workers or volunteers working at community, district or regional level. Some services may need to actively identify potential users if they are not already receiving any social or health care services or participating in school, work or community activities.
  • Assessment Each user requires an individual assessment, taking into account lifestyle, vocation, home environment and physical condition.
  • Prescription (selection) Using the information gained from the assessment, a wheelchair prescription is developed together with the user, family member or caregiver. The prescription details the selected wheelchair type, size, special features and modifications. Also detailed is the training the user needs to effectively use and maintain the wheelchair. 
  • Funding and ordering A funding source is identified and the wheelchair is ordered from stock held by the service or from the supplier.
  • Product preparation Trained personnel prepare the wheelchair for the initial fitting. Depending on the product and service facilities, this may include assembly, and possible modification, of products supplied by manufacturers or production of products in the service workshop.
  • Fitting The user tries the wheelchair. Final adjustments are made to ensure the wheelchair is correctly assembled and set up. If modifications or postural support components are required, additional fittings may be necessary.
  • User training The user and caregivers are instructed on how to safely and effectively use and maintain the wheelchair.
  • Follow-up, maintenance and repairs Follow-up appointments are an opportunity to check wheelchair fit and provide further training and support. The timing depends on the needs of the user and the other services that are available to them. The service may also offer maintenance and repairs for technical problems that cannot be easily solved in the community. It is appropriate to carry out follow-up activities at the community level as much as possible. If the wheelchair is found to be no longer appropriate, a new wheelchair needs to be supplied starting again from step 1.

Understanding Individual User Needs

When planning wheelchair service delivery, it is important to recognize that each user has a unique set of needs. These needs can be categorized as:

  • Physical: the user’s health situation and postural and functional needs.
  • Environmental: where users live and where they need to use the wheelchair.
  • Lifestyle: the things users need to do in the wheelchair to lead their chosen way of life.

Physical Needs. Some users will have a more complex mix of physical needs than others. Users with spinal cord injury, postural deformities, reduced skin sensation and problems with muscle tone (for example spasticity) will require an assessment conducted by personnel with appropriate skills and knowledge. These users will also require more frequent follow-up and support. Here we consider some postural needs of users related to their need for personnel skill and support:

Users of manual wheelchairs without modifications. Children or adults who can sit well without any postural deformities or abnormalities.

Needs: Mobility and postural support for comfort, function and the prevention of postural problems associated with permanent wheelchair use. Mobility and postural support provided through a well-fitted wheelchair and seat cushion.

Users of manual wheelchairs with supportive seating. Children or adults with mild to moderate postural deformities or tendencies. If unaddressed, these deformities will limit comfort, health and function.

Needs: Mobility and postural support to stabilize posture for comfort, function and prevention of further postural problems. Supportive seating provided through individual modifications to a basic wheelchair, or a specialized seating system.

Users of complex supportive seating and mobility equipment. Children or adults with complex, fixed postural deformities. Even with support, many cannot sit normally.

Needs: Mobility and individually prescribed and customized wheelchairs to provide postural support and accommodate fixed deformities. Increased need of skill and support and accommodate fixed deformities.

Environmental and lifestyle needs. These factors require consideration during the assessment. They will influence the choice of a wheelchair, based on performance characteristics, durability and other features. How many users require more than basic wheelchair provision?

In a survey of 147 users conducted at the Western Cape Rehabilitation Centre in South Africa in 2006, it was found that 58% of users required some form of wheelchair modification or basic postural support. Some 22% required complex postural support, while only 20% were able to use a basic manual wheelchair without any modification. A supervisory chief physiotherapist states:

Since our service began, we have found that many users need more than just a basic wheelchair. Many have deformities from living so long without a wheelchair and now need their wheelchair modified so that it fits them. We also have more and more children with cerebral palsy coming to us, and they need wheelchairs with extra postural support. — WCRC Chief Physiotherapist

Good Practice in Wheelchair Service Delivery

This section covers planning and initiating wheelchair service delivery and evaluating existing services. Recommendations are presented in nine areas: good practice in overall service and for each of the eight key steps in wheelchair service delivery. Good practice in wheelchair service delivery includes the following: 

  • Wheelchair services recognize users as clients of the service and adopt a “client-centred approach”. This means, inter alia,that: Users receive information about the process the wheelchair service will use to provide a wheelchair, and the rights and responsibilities of the user in this process. Users are actively involved as members of the service team in all steps leading to the provision of their wheelchair. Services actively collect feedback from users about their opinion of the service and how it may be improved.
  • The service is equally accessible to all users, regardless of gender, age, ethnicity, religion or social status.
  •  The service has personnel trained in its clinical, technical and training roles, who work closely with users to provide advice, assessment, prescription, fitting, training and follow-up.
  • The service has a designated service manager or coordinator.
  • A referral network is in place.
  • The service is well integrated with other rehabilitation and health services.
  • Services are knowledgeable about the range of wheelchairs available locally.
  • Services are able to offer more than one type of wheelchair, giving the user a choice based on the assessment.
  • Wheelchairs are sourced from a range of suppliers, including local and international, depending on their appropriateness and affordability.
  • Services carry out quality control to ensure that every wheelchair is assessed for safety before the user tries it and for safety and correct fit before each user leaves the workshop or rehabilitation centre with the wheelchair.
  • Repair services are available to provide continuing support to users.
  • Services identify local needs and measure their effectiveness in meeting these needs through regular monitoring and evaluation.
  • Services promote teamwork between clinical and technical personnel in providing service to users.

Referrals and Appointments

Objective: The objective of good practice in referrals and appointments is to ensure that users have equitable access to wheelchair service delivery, to increase the efficiency and productivity of the service, and to minimize waiting lists.

Referral System: This pertains to the way in which users access the service. This may be through “self-referral”, whereby users contact the service directly, or through a “referral network”, whereby users are referred by another organization.

Appointment System: This refers to the method of establishing appointment times with users for assessment and prescription, fitting, basic user training and follow-up. The most common method is to list appointment times in a service diary, which are then filled as users are referred. The benefits of an appointment system include reduced waiting times and increased work efficiency.

Waiting Lists: Where there is high demand for the wheelchair service, a waiting list will need to be established. Users on the waiting list can be offered an appointment as the service works through the list. The administration of appointments will depend on the context.

Good Practice in Appointment and Referral Systems

  • When a user is referred to the service, a file is established and an appointment is made or the user is put on the waiting list.
  • Services provide training for referral network personnel to increase their awareness of wheelchair service delivery and to show them how to refer users to the service.
  • Services develop and distribute a form for referral network agencies to complete when referring users.
  • Services use clear guidelines to prioritize appointments. This is particularly important where there are waiting lists. Examples of high-priority users include those with a terminal illness and those at risk of developing life-threatening secondary complications such as a pressure sores.
  • Services set targets and measure their performance in relation to the number of referrals, the length of time between referral and appointment, and reduction of waiting lists.
  • Services have a screening procedure to minimize the scheduling of inappropriate referrals.

Assessment

The objective of good assessment practice is to accurately assess the needs of each individual user in order to prescribe the most appropriate wheelchair available.

Every user requires an individual assessment, carried out by a person or persons with the appropriate skills. The assessment should be holistic, taking into account the lifestyle, living environment and physical condition of the user. It is important that the user and, if appropriate, the family are fully involved in the assessment. Depending on the complexity of the needs, an assessment can take up to two (2) hours.

  • Assessments are carried out in a private, quiet and clean space. This may be a dedicated space within the wheelchair service, at another health care or community facility, or at the user’s home.
  • Assessments are carried out by trained personnel. Culture, age and gender sensitivity while carrying out assessments increases credibility and acceptability.
  • Equipment for the assessment is readily available, including an assessment bed (plinth, mat, table), measuring tape, device for measuring angles (goniometer), foot blocks and infection control supplies.
  • Assessment takes into consideration the user’s physical condition; home, school, work and other environments where the wheelchair is used; lifestyle; size and age.
  • Assessments are clearly documented on an assessment form and filed for future reference.
  • Where a service is unable to meet the user’s needs owing to the lack of an appropriate product or personnel with sufficient skills, the service either; refers the users to another service that is staffed and equipped to service the user, hosts outreach visits of more qualified personnel or, documents the user’s needs to help build a picture of unmet need to guide future service development.

Prescription

The objective of good prescription practice is to match the needs of the user, as identified through the assessment, with the most suitable wheelchair available. Wheelchairs need to be available in different types and sizes and with different options. The prescription (or selection) represents the process of matching the needs of the user with the most suitable available wheelchair. The completed prescription form is a full description of the wheelchair required and selected by the individual user.

  • Users are given the opportunity to see and, where possible, try samples of wheelchairs, cushions and postural support components. This assists users and personnel together in selecting a wheelchair and the necessary features.
  • The importance of features is prioritized to help to make the most appropriate choice from what may be a limited range of available wheelchairs.
  • Each wheelchair prescription is documented, either on the assessment form or on a dedicated prescription form. The prescription details; the type and size of wheelchair, any additional components required (for example pressure-relief seat cushion), any modifications or custom comments required and, the information or skills the user needs to know, or be able to perform, before leaving the service with a new wheelchair.
  • Wheelchair service personnel are given time to write up assessment and prescription notes immediately after each appointment.
  • Services give users an estimate of when their wheelchair will be ready (depending on funding, see below). Where possible, an appointment for the user’s fitting is made at the time the prescription is made.

Funding and Ordering

Objective: The objective of good practice in funding and ordering is to order or procure the selected wheelchair for the user, as early as possible.

Funding: Following prescription, it is possible to closely estimate the cost of the product being recommended. For most services, it will be essential to ensure a funding source has been identified before an order can be placed for equipment. Wherever possible, this should be in the hands of administrative rather than clinical or technical personnel.

Ordering: When not in stock, wheelchairs need to be ordered from an external supplier or procured from the wheelchair service workshop, which usually maintains a stock of different sizes and types of wheelchair.

  • If a wheelchair is not immediately available, services inform the user when the wheelchair will be ready for fitting.
  • Services maintain a stock of wheelchairs and components to ensure faster delivery times.
  • Services encourage suppliers to develop clear order forms and procedures.
  • Services agree with suppliers on delivery times and aim to minimize delays.
  • Services ensure ordering is completed within two working days of completing the user’s prescription, provided that funding is in place.
  • Services have a system in place to monitor pending orders from suppliers.
  • Services have a system for providing feedback to suppliers about quality issues.

Product Preparation

The objective of good practice in product preparation is to prepare the wheelchair for the fitting, including modifications or custom postural support components. Good practice in product preparation include:

  • Each wheelchair being prepared is labelled with the user’s name and a serial number or bar code.
  • Modifications to wheelchairs (permanently altering the frame or a component of the wheelchair) are carried out only by personnel with the appropriate knowledge and skills, since any such modification may have structural and functional implications.
  • The production and installation of custom seating systems or individual postural support components should be carried out by personnel with the appropriate knowledge and skills. This work should also be done in close collaboration with the assessment personnel.
  • All mobility equipment is checked for quality and safety before the user tries it.

Fitting

The objective of good practice in fitting is to ensure that the selected wheelchair has been correctly assembled and to make final adjustments to ensure the best fit. Fitting is a critical step. At the fitting, the user and clinical and technical personnel ensure that the wheelchair fits correctly and supports the user as intended. A fitting may take between 30 minutes and 2 hours or more, depending on the complexity. During fitting, the user and competent personnel together check that:

  • The wheelchair is the correct size.
  • The wheelchair is correctly adjusted for the user.
  • Any modifications or postural support components are fitting correctly.
  • The wheelchair meets the user’s mobility and postural support needs and minimizes the risk of the user developing secondary deformities or complications.
  • All users have their wheelchair individually fitted by personnel trained to do so.
  • Whenever possible, fitting is carried out by the same personnel that assessed the user.
  • The fit of the wheelchair (including any seating or postural components) is first assessed with the user sitting in the stationary wheelchair. When the fit is acceptable, it is then further assessed while the user self propels or is pushed.
  • If the wheelchair fit is not acceptable, further adjustments are made. If an acceptable fit cannot be achieved, alternative equipment or a reassessment may be necessary. The wheelchair cannot be provided to the user until the fit is acceptable.
  • There is provision for more than one fitting appointment for users with more complex needs, such as those with postural deformities.

Training of Users Families and Caregivers

The objective of good practice in training is to ensure that all users are given the information and training they need to be able to use their wheelchair safely and effectively. Key areas of training include:

  • How to transfer in and out of the wheelchair.
  • How to handle the wheelchair.
  • Basic wheelchair mobility.
  • How to stay healthy in the wheelchair, for example prevention of pressure sores.
  • How to look after the wheelchair and cushion and, if appropriate, dismantle and reassemble the wheelchair.
  • Who to contact in case of problems.
  • A user training checklist is completed together with the user, covering the skills the user needs to have in order of priority. The checklist is used by the trainer, and as each skill is taught and demonstrated by the user it is checked off.
  • Where possible, peer trainers (active users with strong wheelchair skills and training in how to teach and support other users) provide basic user training, with supervision by clinical personnel.
  • Wheelchair services link closely with any user groups in the community, providing peer training to strengthen training given at the service.
  • Written or visual materials, including pamphlets or posters in local languages, are used to assist the training of users.

Follow-up Maintenance and Repair

The objective of good practice in follow-up, maintenance and repair is to evaluate the effectiveness of the wheelchair in maximizing the user’s functioning, comfort and stability, and to ensure that the equipment has been maintained appropriately and is in good condition. Follow-up should include a review of:

  • How well the wheelchair has worked for the user.
  • Any problems the user has had in using the wheelchair.
  • The wheelchair’s fit, in particular checking that the wheelchair is providing good postural support for the user.
  • The user’s skills, and whether further training is required.
  • The condition of the wheelchair and whether any adjustments or repairs are required.
  • The user’s ability to care for and maintain the wheelchair, and whether any further training is required.

The frequency of follow-up will depend on the individual needs of the user. Some users should be followed up more frequently than others. As a guide, follow-up appointments are usually made within six months of receiving a wheelchair. Basic wheelchair repair work can often be done locally at bicycle or car repair workshops.

  • Whenever possible, all members of the wheelchair service team are involved in follow-up appointments. This includes clinical, technical and training personnel.
  • The frequency of follow-up is determined by the individual needs of the users.
  • Follow up appointments are given as a priority to users in the following categories: children (whose needs change as quick as they grow), users at risk of developing pressure sores, users who have a wheelchair with postural support modifications or additions, users or family members or carers who have difficulty following the basic training given at the service.
  • Services use follow-up appointments as an opportunity to gather feedback from the user to help evaluate the quality of the service provided.

Manufacturers or Suppliers

Wheelchair services usually receive wheelchairs from manufacturers or suppliers. The scope of these guidelines does not allow a discussion of all production and supply personnel, but a few points are made here concerning managers and technical production personnel.

Management: As well as day-to-day management, managers of wheelchair production facilities are responsible for design selection and production quality. It is therefore important that managers receive feedback from users and wheelchair services about how well their wheelchairs meet their needs.

Technical production personnel: Technical production personnel are concerned with the technical side of wheelchair production. They are not necessarily involved in the fitting or modification of wheelchairs for individual users. This differs from technical personnel in wheelchair services, who are involved in the assembly, modification and fitting of wheelchairs for specific individuals. Nevertheless, some technical personnel, typically those in smaller workshops, may be involved in both the manufacture and fitting of wheelchairs. The term “technical production personnel” as used in these guidelines is limited to wheelchair manufacturers and does not include the provision of services to individual users.

Referral Networks

Referral networks play a crucial role in wheelchair service delivery. Well-functioning referral networks help to ensure services are accessible to users. Referral networks may consist of health and rehabilitation personnel or volunteers working at community, district or regional level.

The importance of a strong link between specialist services and rehabilitation or health care programmes is stressed in a joint statement of the International Society for Prosthetics and Orthotics and the World Health Organization.

Wheelchair services are an example of a specialized service that cannot always be fully provided within every community. In developing countries, the majority of those people with disabilities live in rural areas and find it difficult to access rehabilitation services, which are often restricted to large cities. Health and rehabilitation workers therefore need to play a proactive role in ensuring that people living in rural areas can also access wheelchair services without difficulty. The role of referral networks in wheelchair service delivery can include:

  • Identifying and referring people requiring wheelchairs.
  • Liaising between the users, their families and the wheelchair services to facilitate assessment, fitting and follow-up.
  • Reinforcing wheelchair service training such as pressure sore prevention, prevention of secondary complications, wheelchair maintenance and mobility skills.
  • Providing support, advice and possibly assistance in adapting the user’s home environment.
  • Encouraging measures to facilitate accessibility in the community.
  • Providing information to the wheelchair services about the acceptability and use of prescribed wheelchairs.
  • Assisting the user to arrange repairs.
  • Promoting the benefits of wheelchairs.

Wheelchair Service Delivery Personnel Roles

Wheelchair service personnel carry out managerial, clinical, technical and training duties. These roles may be fulfilled by personnel from a range of training and educational backgrounds. They may also overlap: in a small service, for example, one person could carry out both the clinical and technical roles. In another scenario, one person could carry out the clinical, training and management roles with the support of a part-time technician.

At times, particularly when working with users who have complex needs, personnel may draw on the expertise of other specialists such as occupational therapists, physiotherapists, speech and language therapists, paediatricians, neurologists, physiatrists, orthotists, prosthetists and orthopaedic specialists.

Management Role: For a wheelchair service to operate effectively, a designated manager is critical. The manager ensures a framework is in place to enable the wheelchair service to operate. This includes adequate staffing, facilities, funding, products, referrals and appointment systems. Managers also play a key role in promoting wheelchair services. The manager therefore requires a thorough understanding of wheelchair service delivery in addition to general management skills. The duties of wheelchair service managers should include.

  • Building awareness of wheelchair service delivery among all stakeholders.
  • Developing a referral network through promotion of the wheelchair service and its functions.
  • Organizing training opportunities for referral network personnel.
  • Ensuring the service is accessible to all users within the service area, including women, children and minority groups.
  • Managing waiting lists.
  • Identifying and securing sources of funding to support the service.
  • Facilitating the development and training of service personnel.
  • Evaluating the effectiveness of the service in meeting users’ needs.
  • Continuously improving service quality.
  • Developing links with disabled people’s organizations and community-based rehabilitation programmes.
  • Asssisting in the formation of wheelchair users’s groups.

Clinical Role: Clinical personnel work directly with the user in assessment, prescription, fitting and follow-up. Ideally, the clinical personnel work closely with technical personnel, particularly on prescription and fitting. The main duties of clinical personnel include:

  • Wheelchair service delivery, following the eight-step process listed earlier.
  • Quality control to ensure equipment is adjusted correctly and is safe for each user.
  • Training users in mobility and health issues, or supervision of such training provided by a trainer.
  • Follow-up with users to ensure that equipment continues to be appropriate to their needs.
  • Record keeping and documentation.
  • Education of referral network personnel.
  • Keeping up to date with the range of available wheelchairs.
  • Participation in overall service evaluation.

Technical Role: Technical personnel ensure that the technical requirements of the prescription are met through the correct assembly or modification of the wheelchair. Technical personnel have direct contact with users, at least in the prescription and fitting stages. When working with a user who requires modifications or postural support, it is increasingly important that technical personnel are directly involved in the user’s assessment, fitting and follow-up. The main duties of technical personnel include:

  • Assembling or preparing wheelchairs according to prescription.
  • Making or assembling modifications or custom postural support.
  • Training users in wheelchair maintenance and basic repair, or supervising such training provided by a trainer.
  • Ensuring that each wheelchair and any modifications are technically safe before each fitting and before the user leaves the service with the new equipment.
  • Keeping records and documentation.
  • Following up users to ensure equipment continues to be appropriate.
  • Facilitating maintenance and repairs of wheelchairs and associated equipment.
  • Participating in overall service evaluation.

Training Role: One of the key steps in wheelchair service delivery is basic skills training for wheelchair users. The bulk of the training may be fulfilled by clinical or technical personnel or by dedicated trainers. They also provide users with the necessary advice on maintaining their wheelchair. Experienced, well trained wheelchair users (“peer trainers”) are useful in training other users.

Provided with the right resources and training, peer trainers may have some advantages over trainers who are not users. Such advantages include an ability to empathize and to draw on first-hand experience. For those receiving a wheelchair for the first time, there is added value in training given by a peer trainer. By working with peer trainers, users are better able to recognize their own potential. The main duties of trainers include:

  • Training users and caregivers, individually or as a group, in: transferal in and out of the wheelchair, wheelchair handling, basic wheelchair mobility, health issues specific to wheelchair use (pressure sore prevention, etc.), wheelchair maintenance.
  • Participating in routine and more intensive follow-up for those users at risk, or who require additional training and support.
  • Educating referral network personnel.
  • Participating in service evaluation, focusing on the needs of users.

In addition, trainers could become involved in: 

  • Activities to promote the wheelchair service.
  • Liaison with disabled people’s organizations and community-based organizations.
  • Referral of users to relevant community programmes such as disabled people’s organizations, vocational schemes and peer group training.

For 11 years now, the Motivation Romania Foundation (MRF) based in Bucharest has provided peer training. The MRF wheelchair service and peer training programme is based on the principle that all wheelchair recipients should undergo peer training (including, but not limited to, wheelchair skills) to maximize their independence. The peer training team currently consists of four users and a physiotherapist. Each year, some 160 users access the peer training programme, which includes:

  • Training in wheelchair skills
  • Individual and group discussions, in which users can talk about the challenges they have faced and try to find solutions together.
  • Provision of information, for example about dealing with health problems.
  • Participation in sports and social activities to facilitate the development of outgoing, people-oriented attitudes and prevent isolation.

Peer training is carried out at the MRF centre and through regular peer training camps. Peer trainers are recruited from among former recipients of peer training. They receive training in teaching and counselling from experienced peer group trainers, thus enabling them to take on the role themselves.

The costs of the peer training programme are covered by the Romanian Ministry of Labour and Social Protection, the National Authority for People with Disabilities, and national and international donors. 

An overview of the clinical, technical, training and management duties of wheelchair service personnel. 

Overview of the duties of wheelchair service personnel

Monitoring and Evaluation

The need to measure performance. Monitoring and evaluation of a wheelchair service can help identify those areas that are successful and those that can be improved. Monitoring is the regular ongoing collection and analysis of information to track the quality and effectiveness of the wheelchair service. Evaluation refers to an overall evaluation, usually conducted over a short period of time. Evaluations are often carried out annually or sometimes biannually.

Information gained through regular monitoring is often used as part of an overall evaluation. It is recommended that services establish a system for regularly monitoring the service, and conduct annual overall evaluations to assess service performance and impact. Monitoring and evaluation can provide important information that enables services to:

  • Improve the quality of services and products.
  • Improve service processes such as referral, appointments and follow-up.
  • Contain costs by increasing efficiency.
  • Demonstrate the benefits of wheelchair service delivery for users.
  • Demonstrate the effectiveness of the service.
  • Identify and quantify unmet needs.
  • Plan further development of the service.
  • Allocate resources appropriately.
  • Justify current and proposed service funding.
  • Develop stronger partnerships with service recipients.
  • Enhance credibility and funding opportunities. 

Monitoring

Regular monitoring can be established as follows:

  1. Identify the areas and activities of the service that should be routinely monitored. Examples are the rate of referrals, waiting times, the number of users receiving wheelchairs, the types of wheelchair prescribed, the number of follow-ups and the level of user satisfaction.
  2. Set “performance targets” for these areas and activities. A performance target is a statement of how well the service would like to perform in that area. This may often be linked to funding. For example, funding may have been provided to the service based on agreed objectives or targets. Performance targets should be realistic, taking into account the resources available.
  3. Identify the information that needs to be collected in order to be able to monitor service performance for each area – and how it will be collected. Ideally, gathering information should be part of the service’s normal record keeping, and should thus require very little additional work by service personnel.

Now we visit an example of service areas that could be monitored, performance targets, and ways to collect information for each service area. It is important to note that the performance targets are examples only; actual targets need to be worked out according to the resources available to each service. Examples of service areas that could be monitored, performance targets, and ways of collecting information:

Wheelchair service monitoring

Feedback from users: In addition to the routine collection of monitoring information, it is recommended that services establish methods of regularly gathering feedback from users and their families. There are several ways in which such feedback can be gathered.

  • A few questions about the service can be formulated and put to users after they have received their wheelchair.
  • A short questionnaire can be developed, asking users for their thoughts on the performance of the service. This could be offered to every user or to a specified number of randomly selected users each month.
  • Users can be encouraged to write down their impressions of the service and post them in a “feedback box”. Feedback can be anonymous, thus allowing people to feel more comfortable about providing honest feedback. It is important to note that this type of system is open only to those with a sufficient level of literacy, and should therefore not be the only method used to gather feedback.

Analysing the collected information. The information collected through regular monitoring and user feedback will be most useful if it can be centrally stored and organized. A basic database can be very useful for this where computers and personnel are available. Alternatively, information can be organized and analyzed manually.

Once information is organized, it is possible to measure how the service is performing against the performance targets. A regular analysis of information can be used to identify problems and action can be implemented to solve the problems. For example, if fewer referrals than expected are being received, a service may choose to contact all referral sources to remind them about the service or offer additional training.

Evaluation

An overall evaluation is more comprehensive than ongoing monitoring. An evaluation provides an overview, highlighting the service’s strengths and weaknesses. Previous evaluation reports can be used as a basis for subsequent evaluations.

Service evaluations can be carried out externally or internally. An external evaluation involves having one or more people from outside of the service carrying out the evaluation. This can be useful, as external evaluators will view the service from a different perspective. Internal evaluations can be carried out by one or more personnel who have been designated the responsibility to gather and analyse the necessary information. The use of computers in data collection, programme monitoring and follow-up will facilitate the evaluation of service provision.

Suggestions for gathering evaluation information for some key service areas. 

Quality of service delivery. The good practice recommendations made in Section 3.3 of these guidelines can be used as criteria to assist in evaluating the quality of service delivery.

Users served and the intervention they received. Information from ongoing monitoring should enable evaluators to quantify the number of users provided with a wheelchair, training and follow-up; the different types of wheelchair provided; and the number of users with needs that could not be met by the service. A thorough evaluation would also include information on users accessing the service, including age, gender, ethnicity, disability and home location.

Cost of service, including cost of products and service delivery. Information from ongoing monitoring should enable evaluators to review and summarize the cost of the service. An audit of accounts may also be used to determine the cost of products and services.

Staffing, numbers of personnel and their roles and competences. Evaluators can assess numbers and roles of personnel by talking to service management or reviewing personnel records. Staff competences can be assessed by observing personnel carrying out their duties. Good practice recommendations=, the personnel roles, and the clinical competences, are criteria to assist in evaluating personnel competence. Staff educational records should be reviewed to help determine competences and professional development. Feedback from users and individual interviews with personnel can help to identify strengths and weaknesses in the staffing structure.

Facilities and equipment available to the service. Evaluators can assess the suitability of facilities and equipment by observing the service in practice. Feedback from users and individual interviews with personnel can help to identify any strengths and weaknesses in service facilities.

Impact on users and their families. Information may be gathered from users and their families on the impact of the service. Measures can include increased participation in family or community activities (for example education, employment in or outside of the home, participation in social activities) and increased earning potential of wheelchair users or their families. Methods of gathering information include the following:

  • Evaluators may review assessment and follow-up forms. Assessment forms can provide information about users and their families before they receive a wheelchair through the service. Follow-up reports can provide information about how the service has affected the lives of the user and his/her family. 
  • Home visits will enable evaluators to meet the users of the service and see for themselves what impact there has been. Home visits may provide additional information not gained through a follow-up appointment carried out at the service. 
  • A detailed survey may be developed to assess the service impact on the quality of life of users, including participation in school, employment and other activities.
  • Users (and family members) may be gathered as a focus group to provide evaluators with information about how they believe the service has affected them.

Conclusions

Wheelchairs need to be provided together with services. Existing rehabilitation personnel can be utilized to provide wheelchair services. Integrating wheelchair services with existing health or rehabilitation services is recommended. Where possible, the needs of users should be met at community level. Wheelchair services facilitate the assessment of individual user needs, provide an appropriate wheelchair, train users and caregivers, and provide ongoing support and referral to other services.

Each user has a unique set of physical, environmental and lifestyle needs. Groups of personnel involved in wheelchair service delivery include manufacturers and suppliers, referral networks and service personnel. The main roles of service personnel are managerial, clinical, technical and educational. Peer trainers play an important role in wheelchair provision. Wheelchair provision should be regularly monitored and evaluated, especially in helping to identify those areas that are successful and those that need to be improved.

Resources

  1. Rushman C, Shangali HG.Wheelchair service guide for low-income countries. Moshi, Tanzanian Training Centre for Orthopaedic Technology, Tumani University, 2005.
  2. Sheldon S, Jacobs NA, eds. Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India, 6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007 http://homepage.mac.com/eaglesmoon/WheelchairCC/WheelchairReport_Jan08.pdf, accessed 8 March 2008).
  3. McCambridge M. Coordinating wheelchair provision in developing countries. In: Proceedings of the RESNA 2000 Annual Conference: Technology for the New Millennium, Orlando, Florida, 28 June – 2 July 2000. Atlanta, GA, RESNA, 2000:234–236. 
  4. The manual wheelchair and its use. Stockholm, Swedish Institute of Assistive Technology, 1990 (In Swedish).
  5. Oderud T. Design. In: Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India, 6–11 November 2006. Copenhagen, International Society for Prosthetics and Orthotics, 2007. 
  6. The relationship between prosthetics and orthotics and community-based rehabilitation. A joint ISPO/WHO statement. Copenhagen/Geneva, ISPO/WHO, 2003 http://www.who.int/disabilities/technology/po_services_cbr.pdf, accessed 10 March 2008).
  7. Helander E. Prejudice and dignity: An introduction to community based rehabilitation, 2nd ed. New York, United Nations Development Programme, 1999
  8. Empowering the rural disabled in Asia and the Pacific. Rome, Food and Agriculture Organization of the United Nations, 1999 http://www.fao.org/sd/PPdirect/PPre0035.htm, accessed 10 March 2008).

 

Manual wheelchair sideways stability wheel camber

Manual Wheelchair Design and Production

With permission from the World Health Authority we bring you part II of our series on increasing the quality and range of available wheelchairs in less resourced areas. In this edition we cover the four main principles of Manual Wheelchair Design and Production as follows:

  1. DESIGN Outlines methods for designing or selecting a manual wheelchair.
  2. PERFORMANCE Describes different types of wheelchair production, function and supply.
  3. EVALUATION Sets out the advantages and disadvantages of different wheelchair designs.
  4. DURABILITY Suggests how to evaluate wheelchairs in terms of performance, seating and postural support, as well as strength durability and safety.

Testimonial From Cambodia

Wheelchair advocate Cambodian national Tun Channareth Reth 1997 Nobel Peace Prize winner

Wheelchair advocate Cambodian national Tun Channareth Reth 1997 Nobel Peace Prize winner

In 1982 Tun “Reth” Channareth stepped on a landmine. He later had both of his legs amputated. Much of his family was killed by Pol Pot’s soldiers in the Vietnamese invasion of 1978. Forced to leave Phnom Penh with his remaining family in 1979 Reth received vocational training at a Thai refugee camp, where he stayed for 13 years.

In 1993, Reth moved back to Cambodia and was employed and trained as a wheelchair builder in a local wheelchair workshop. Reth himself received a three-wheeled active-style wheelchair and a tricycle through the workshop. The mobility provided by both the wheelchair and the tricycle has enabled Reth to work, care for his wife and six children, and become an active campaigner against landmines.

Reth is now an ambassador for the International Campaign to Ban Landmines (ICBL), an initiative he was co-awarded the Nobel Peace Prize for in 1997. He has travelled the world urging governments to make landmines history.

I have to admit that what happened to me, being a landmine victim, helped me realize that life does not end in one or more difficulties. Also, through the help of so many people around me I was able to go beyond the tragedy in my life. Now I am an active spokesperson for ICBL. Whenever there’s an opportunity to speak about advocacy to ban landmines, I make a sincere appeal to people and governments, asking them to support this campaign, to give more assistance to help the victims and their families. Also, at present I am working in the Jesuit Service Cambodia – Siem Reap team, in the wheelchair team and outreach programs. As of now, we are able to reach people in 222 villages, 90 communes and 12 districts. It is not an easy job for a double amputee, but I am happily fulfilled. – Reth

Wheelchairs Changing Lives

The purpose of these manual wheelchair design and production guidelines is to increase the quality and range of manual wheelchairs available in less-resourced settings, and where people simply cannot afford a wheelchair. Implementation of these guidelines aim to enrich the lives of wheelchair users in third world countries and lead to:

  • A wider variety of wheelchair types and designs.
  • Wheelchairs that are safe and meet minimum requirements.
  • Lower long-term costs of wheelchairs.
  • More available information about wheelchairs.
  • National standards for wheelchairs.

These manual wheelchair design and production guidelines have been developed by the WHO (World Health Authority) to apply to manual wheelchairs with a variety of features. Including all levels of adjustability, three-and four-wheeled wheelchairs, folding and rigid wheelchairs, and adult and pediatric wheelchairs. While the guidelines are not written specifically for devices such as hand-powered tricycles, the principal recommendations may nevertheless be applicable. These guidelines can be used to design wheelchairs and select pre-existing wheelchair designs for production and supply to wheelchair services.

Manual Wheelchair Design 1: Wheelchair Design

The objective of manual wheelchair design is to produce wheelchairs that perform well and can provide appropriate seating and postural support without compromising strength, durability and safety. This can be achieved when government authorities, manufacturers, engineers, designers, service providers and users fulfill their respective roles with respect to design.

It is recommended that government authorities develop and adopt national wheelchair standards applicable to all wheelchairs supplied in a country. This includes all locally produced wheelchairs and imported wheelchairs, whether donated or purchased.

The International Organization for Standardization (ISO) has developed international standards for wheelchairs, known as the ISO 7176 series. This series specifies a terminology and testing methods for evaluating wheelchair performance, size, strength, durability and safety. Many national standards committees have adopted the ISO 7176 series, or an individually tailored form of the series, as their own wheelchair standards.

All requirements in the ISO 7176 series may not reflect typical conditions in less-resourced settings, as some of the requirements were designed to simulate the conditions in city environments with smooth roads. When developing national standards, it is therefore important to consider environments, the weights and sizes of users, typical uses, and the available wheelchair and allied technologies (such as bicycle/tricycle) within the country.

Governments, manufacturers and suppliers need to work together to establish a sustainable supply of wheelchairs that meet national standards. Whether produced in the country or imported, it is important that the range of wheelchairs meets the diverse needs of users. Governments and organizations are encouraged to support manufacturers in using test equipment to improve the quality of their wheelchairs, to make efforts to minimize the costs of testing for local manufacturers, and to support the dissemination of wheelchair quality evaluations.

The resources needed to implement these guidelines can be minimized through joint planning and cooperation among government authorities, nongovernmental organizations, international nongovernmental organizations, disabled people’s organizations, foreign governments, bilateral aid agencies and the private sector. As much as possible, existing infrastructure and expertise should be used, supported and further developed.

Wheelchair Design Principles

Individuals ought to be trained to design, produce and test wheelchairs that meet these guidelines. This can be done by introducing these guidelines to students or practitioners of related disciplines.

Wheelchair evaluation and testing results should be recorded and made available to all stakeholders. Such information will help stakeholders to select the most appropriate wheelchair for a given use. Service providers, users and advocacy groups are also encouraged to use the information provided to communicate with wheelchair manufacturers and suppliers about their specific needs and how available wheelchairs meet their needs.

Stakeholders involved in the design and production of wheelchairs include purchasers, manufacturers, designers, evaluators and users. Experienced wheelchair users can often contribute substantially in designing wheelchairs. Key resources required to implement the design and production guidelines include:

  • Engineers, designers, users, technicians and manufacturers.
  • Facilities and equipment to produce or assemble wheelchairs.
  • Facilities and equipment to evaluate wheelchairs.
  • Product evaluators.

Wheelchair designs vary greatly to take account of the diverse needs of users. To ensure wheelchairs are appropriate, designers and providers must thoroughly understand the needs of the intended users and their environments. Users’ needs are best met when there is a variety of models from which to choose.

Basic Manual Wheelchair Parts

Basic Manual Wheelchair Design Parts

Basic Manual Wheelchair Design Parts

A cushion is to be considered an integral part of a wheelchair, and is therefore to be included with all wheelchairs. People with spinal cord injuries or similar conditions require pressure relief cushions that prevent the development of life-threatening pressure sores.

Wheelchairs should be designed to enable their users to participate in as many activities as possible. As a minimum, a wheelchair should enable the user to lead a more active life without having a negative effect on their health or safety. Comfort and safety are two important factors affecting the quality of life of long-term users.

The health and safety of users should never be compromised in order to reduce costs. Although it may seem that any wheelchair is better than no wheelchair, this is not true when the wheelchair causes or contributes to injury or other health risks. A wheelchair should be designed to ensure the user’s safety and health. There are many ways in which users can be injured by their own wheelchairs, as illustrated by the following examples:

  • A wheelchair without a cushion or with an inadequate cushion can cause pressure sores. This in turn may require the user to spend many months in bed, without appropriate care and treatment this often leads to bedsores, secondary complications and even premature death.
  • Unstable wheelchairs can tip and lead to users falling and injuring themselves.
  • Wheelchairs that are too wide or are unduly heavy can cause shoulder injuries.
  • Sharp edges on surfaces can cause cuts that in turn can lead to infection.
  • Poor design can result in places on the wheelchair where the user or others can get their fingers or skin pinched.
  • Wheelchairs that cannot endure daily use in the user’s environment may fail prematurely and can injure the user.

Wheelchairs used outdoors are subjected to greater wear and tear than those designed for indoor use or use on smooth roads and paths. A wheelchair must be strong enough not to suffer a sudden failure while being used. The wheelchair should be built to have the longest possible useful life and require the fewest repairs. A wheelchair should be designed so it can be repaired near the user’s home if it fails, and replacement parts should be easily available.

Wheelchairs should be appropriate for the environment in which they will be used and for the specific people who will use them. One wheelchair design will not suit everyone. When designing or selecting wheelchairs it is necessary to think about the environment and the way in which the wheelchair may be used.

When designing a new wheelchair, or selecting a pre-existing wheelchair design, it is important to know where the wheelchair will be produced. In different locations, the technical skills, available technology, materials and components available for production will vary. For this reason, a wheelchair designed for one region may not be suitable in another region. However, the fundamental design might be quite similar.

  • Riding for long distances over rough roads.
  • Going up and down many kerbs every day.
  • Accessing built environments: narrow doorways, small turning areas, steep ramps, desks and tables, bathroom facilities (e.g. sitting and squatting toilets).
  • Exposure to moisture such as rain, high humidity, snow, ice, hail and body fluids such as urine and sweat.
  • User showering while sitting in the wheelchair.
  • Exposure to extreme temperatures.
  • User transporting goods on the push handles, upholstery, footrests or other parts of the wheelchair.
  • Passengers riding on footrests and armrests.
  • People lifting the wheelchair by one armrest, footrest or push handle when the wheelchair is occupied.
  • Transporting the wheelchair in confined spaces or other cramped or crowded conditions.

The following categories can be used to describe and evaluate wheelchair designs.

  • Functional performance, how a wheelchair performs for different users in different environments. The functional performance of a wheelchair is determined by its design and features.
  • Seating and postural support, how a user’s body is supported by the wheelchair. This includes comfort and pressure relief.
  • Strength, durability and safety, considers the safety of the user, the resistance to breaking and the durability of the wheelchair.

Wheelchair users are strongly encouraged to be involved in the design and selection process. From experience, users are the most knowledgeable about their own physical, social and cultural needs.

Wheelchair Design Criteria

1. Design brief. This is a written statement of the needs and criteria for the wheelchair. The criteria include environmental constraints (physical, cultural, social), local production resources, such as materials and human resources, performance requirements and target price. Design briefs should be developed in consultation with users and others familiar with the needs of intended users, and according to available resources. The design process can be an effective tool for selecting wheelchairs for large-scale provision to a region or for individual users.

2: Design/select wheelchair. After the design brief is written, design ideas are developed and prototypes are built and tested in the workshop. The process of designing, prototyping and testing may need to be repeated several times until the prototype meets the performance requirements of the brief. A design brief can also be helpful in selecting a wheelchair.

3: Product testing. When a prototype meets the performance criteria, it should be tested to ensure it meets strength and durability requirements. If the wheelchair fails the tests, the design may need to be changed.

4: User trials. Once the prototype has met all the performance, strength, durability and safety requirements, it should be tested by users who live in the environment the wheelchair is designed for. User trials allow for feedback from users, who are the most knowledgeable about the performance of the device.

5: Production and supply. If the user trials are successful, production and supply of the wheelchair may begin.

6: Long-term follow-up. At this point, long-term follow-up should be used to assess the performance of the wheelchair over time (for example, over several months). The feedback thus obtained should then be used to improve the design.

Wheelchairs may be produced nationally or imported. To provide a range of wheelchairs, some countries may choose to support both national production and importation. Each supply method has an appropriate application. With many different needs within a region, a variety of supply methods may be suitable, the long-term goal being sustainable solution.

It is recommended that all wheelchairs, irrespective of supply method, meet or exceed national wheelchair standards and be repairable locally. When determining whether to acquire wheelchairs via import or local production, decision-makers are advised to balance a variety of factors. These include:

  • The needs of local wheelchair users.
  • The quality and variety of wheelchair models.
  • The long-term reliability of supply of wheelchairs and spare parts.
  • The possibility of influencing the design, features, materials, etc.
  • The purchase price.
  • The cost of repair and replacement.
  • The effect on local employment and wheelchair production.
  • Coordination of supply with an overall plan for wheelchair provision.
  • The amount and term of the funding available.
  • Policies and strategies, including long-term sustainability.

Manual Wheelchair Performance 2: Wheelchair Performance

Functional performance is how a wheelchair performs for different users in different environments. The functional performance of a wheelchair is determined by its unique design and features. There are many compromises to consider when designing or selecting for different uses. This section provides information on the key features of a wheelchair that affects the main categories of performance and how to evaluate them. It also outlines compromises that need to be considered when choosing different design features.

To meet the functional performance needs of individual users, a range of wheelchair designs and sizes are needed. Wheelchair stability affects how safe the wheelchair is, and how well the user can carry out activities in the wheelchair. Wheelchair tipping causes many injuries for users.

Static stability relates to the stability of the wheelchair when it is not moving. This determine whether the wheelchair will tip over (where some wheels lose contact with the ground) when the user, for example, leans over to pick something up off of the ground or transfers into or out of his or her wheelchair.

Dynamic stability relates to the stability of the wheelchair when moving. This determines whether the user can ride over bumps or sloped surfaces without tipping. The design features used to increase wheelchair stability have secondary effects on other functional performance characteristics. For example, moving the front castor wheel forward increases stability but reduces the maneuverability of the wheelchair in confined spaces. Apart from seat height, stability in each direction is sensitive to several design factors.

Manual wheelchair rearward stability anti-tipping bars with wheels

Rearward stability (resistance to tipping backwards) is affected by the rear axle position in relation to the user’s centre of gravity. Increasing rearward stability has associated advantages and disadvantages. For example, anti-tip devices can be useful for some users who are unstable or are learning to perform “wheelies” (whereby the user raises the front castor wheels and balances on the rear drive wheels). However most anti-tip designs restrict the wheelchair’s ability to travel over uneven surfaces (such as kerbs or dips).

Forward stability is affected by the size and position of the front castor wheel in relation to the user’s centre of gravity. A good example increasing forward stability and the associated advantages and disadvantages is large front castor wheels. Front castor size significantly affects dynamic stability, with larger front wheels the wheelchair will be able to roll over larger obstacles without being stopped and tipped forward. Although larger front castor wheels need more room to swivel so the wheelchair design will need to be much longer or wider to allow room for the user’s feet.

Sideways stability is affected by wheelchair width. The further out to the side of the wheelchair the front and rear wheels touch the ground, the more the chair will resist tipping over sideways. Consequently of disadvantage a wide wheelchair is more difficult to get through narrow doorways. Camber also increases the width of the wheelchair when it is folded.

Manual wheelchair sideways stability wheel camber

Paraplegic wheelchair users with advanced mobility skills and good trunk control can partially compensate for some of the wheelchair’s instability if they can balance on the rear wheels (perform a wheelie) and if they can shift their weight forwards, backwards or to the side to prevent tipping. The fact that quadriplegics (tetraplegics) have very limited to no balance must also be taken into consideration. Increasing the camber on rear wheels makes a wheelchair more stable but also harder to push.

Maneuverability around obstacles determines the user’s ability to maneuver in an environment with confined spaces, such as a toilet with a narrow door and very limited space.

Moving through narrow passageways the narrowest space through which a wheelchair can pass is determined by its width, measured from the outermost point on each side. The ability to move through narrow passageways can be improved by making the wheelchair narrower.

Pulling up close to surfaces and objects how close users can get to surfaces and objects they cannot roll under, such as toilets, low tables, counter tops, centre-post tables and bathtubs, is determined by how far the wheelchair extends both forwards and to the side of the seat. A user can get closer to surfaces and objects if the wheelchair is shorter in height.

Rolling under surfaces where the user’s ability to pull up to a table is determined by the height of the user’s knees (the length of the user’s lower leg plus the minimum safe height of the footrest above the ground). Some types of fixed armrest also prevent users from pulling up to tables and counters.

Turning around in confined spaces where the smallest area in which a wheelchair can turn around is determined by its maximum diagonal measurement.

Maneuverability over obstacles determines the user’s ability to negotiate obstacles such as soft ground or raised obstacles. When negotiating obstacles, the user is at risk of tipping backwards or forwards and falling out of the chair (a common cause of injury); thus it is also important to consider stability when evaluating a wheelchair’s ability to maneuver over obstacles.

Maneuvering over soft ground such as mud, sand, grass, gravel and snow, depends on the area of contact that the wheels have with the ground and the amount of weight on the wheel. There are many ways of improving maneuverability over soft ground each with their associated advantages and disadvantages.

Maneuvering over raised obstacles such as bumps, kerbs or rocks, depends on many factors. The size of the castor wheel, the distance of the castor wheel from the user’s centre of gravity and the springiness of the castor wheel, all have a significant effect. Castor flutter is also a result of hitting bumps at speed.

Pushing efficiency is related to the amount of energy required for the user to push the wheelchair over a given distance. Lighter wheelchairs are normally easier to push, but there are many factors and wheelchair features that affect how difficult or easy it is to push one’s wheelchair. A wheelchair with a broken or misaligned component (e.g. untrue wheels, distorted frame, broken bearings causing friction, unparallel wheels or poorly inflated pneumatic tyres) resists the user’s forward motion, thereby wasting much of the user’s pushing energy.

Ability to transfer into and out of the wheelchair depends on the type of transferral that is easiest for the user and whether the wheelchair’s structure impedes transferral. For users who transfer by pivoting their bottom about their knees (side transfer), there must be sufficient space at the end of the seat surface to be able to move their body past the armrest. Removable armrests are an advantage when transferring but consider the disadvantage of removable armrests being lost or damaged.

Transporting the wheelchair for long-distance travel by, for example, bus, taxi or train, take into account of the design and size of the wheelchair and the materials used in its construction. Weight is a crucial factor in transporting a wheelchair, and weight is determined by the types of component (wheels/frames) used and by the construction materials (e.g. steel, steel/aluminum alloy or other metal). Reducing weight has a direct effect on durability and cost. Design and size are equally important, foldable and smaller wheelchairs being easier to carry.

Wheelchairs that can break down (pull apart) are easier to lift and transport however removable parts can get lost, bent or broken. Standard push-button quick-release axles (rear wheels) are convenient to transport but are not available everywhere, they are more expensive than fixed axles, and have a shorter life where conditions of use are rough. Of further disadvantage, sand, dust and moisture can cause the locking mechanism to seize. This may cause the axle to slip out of the axle socket resulting in the wheel to falling off the wheelchair and injury.

Reliability of a wheelchair is determined by its durability and the length of its useful life. In the case of failure, the frequency and difficulty of repair also determines the reliability of a particular model of wheelchair. Ways of improving the reliability of a wheelchair include:

    • Better materials and technologies at an affordable cost.
    • Fewer removable parts.
    • Non-folding design where folding is not a necessity.
    • Use of materials that can be repaired or replaced locally.
    • Regular servicing, repair and maintenance.
    • Knowledge by the user of the product and its use, care and maintenance.

Manual Wheelchair Evaluation 3: Wheelchair Evaluation

It is recommended that a wheelchair be evaluated based on the functional performance measures and that the results be available to the users and purchasers. The functional performance areas in which a wheelchair should be evaluated or reported on are:

  • Static stability.
  • Dynamic stability.
  • Rolling resistance.
  • Ability to repair/availability of components.
  • Overall dimensions, mass and turning space.

Static stability and overall dimensions, mass and turning space tests and reporting techniques are covered in ISO standards 7176-1, 7176-5 and 7176-7.

An appropriate wheelchair will establish a balance between adequate seating and postural support as well as mobility. Good postural support is important for everyone, especially for people who have an unstable spine or are likely to develop secondary deformities like scoliosis (curvature of the spine). The significance of good seating and postural support can mean the difference between the user being active and an independent member of society and the user being completely dependent and at risk of serious injury or even death.

All body contact surfaces provide seating and postural support. Together, these parts of the wheelchair help the user to maintain a comfortable and functional posture and to provide pressure relief. This is very important for spinal cord injury wheelchair users with paralysis and other problems with skin sensation.

As a basic guide to the design and selection of wheelchairs we don’t cover in detail specific wheelchairs that provide a high level of adjustability or custom adaptations for high level tetraplegics with spinal cord injury who require complex postural support. That said, any wheelchair and cushion should meet the seating and postural support requirements of the user(s) including the size of the wheelchair, the type of cushion, and the adjustability and ergonomic factors of the wheelchair.

Wheelchairs should be provided with a cushion that is appropriate to manage the user’s risk of developing pressure sores. A wheelchair should be evaluated based on the seating and postural support measures, and the results should be available to the users and purchasers. Cushions should be evaluated and rated based on their ability to provide comfort, pressure relief and postural support, and the results should be made available to the users and purchasers.

Cushions Slings And Solid Seats

The two most common types of seat base are “sling seats” and “solid seats”. Sling seats (also known as slung seats) are made of a flexible material such as canvas or vinyl. Solid seats are not flexible and are often made of wood, metal plate or plastic.

Failure of the wheelchair seat and the cushion is a common problem. Sling seats made of poor quality or inappropriate materials can quickly stretch, sag and tear. Wheelchair cushions are not designed to work on such seats made of poor quality or inappropriate materials. This means that the user ends up sitting on an unstable seat without pressure relief. The result can be that the user will develop pressure sores or stop using the wheelchair owing to discomfort.

Some design solutions include tension-adjustable sling seats made with straps and stretch-resistant fabric and pressure-relief cushions for wheelchairs with sling seats provided with a contoured bottom surface to accommodate the curve of the sling. Many cushions can easily be modified for use on a sling seat by cutting off the lower, outer edge from front to back on each side to accommodate the seat rail and the curve of the sling.

  • Wheelchair seats should have a continuous surface with no breaks that might cut or pinch the user’s skin.
  • The angle of the seat, in relation to the horizontal, should be between 0 and 12 degrees (with the front portion of the seat higher than the rear portion of the seat).
  • The seat must be level from side to side.
  • A range of seat sizes should be available to fit a range of body sizes.
  • Sling seats should be designed with materials that do not stretch over time from the weight of the user.
  • Sling seats and solid seats should be used with cushions designed or modified for use on a sling seat and solid seat respectively.

An inadequate pressure-relief cushion is the one component of a wheelchair that is most likely to cause pressure sores, serious injury or premature death. Wheelchair cushions are used for three reasons: comfort, pressure relief and postural support. For many users, a cushion that provides some comfort will help them to use the wheelchair for a longer time.

Spinal cord injury users with limited or no skin sensation are always at risk of developing pressure sores when using a wheelchair without a proper cushion. These users must use a pressure relief cushion to help reduce this risk and maintain a healthy lifestyle.

Many users require some adaptations or modifications to their cushion to help provide additional postural support or pressure relief. Wheelchair manufacturers need to either keep a good stock of different types and sizes of cushion or have the capacity to produce and modify a cushion as and when needed.

  • The cushion should be removable from the wheelchair.
  • The cushion should be easy to clean using basic materials such as soap and water.
  • The cushion should be an appropriate size to fit on the seat base.
  • Correct cushion use and the way in which it should be placed on the wheelchair seat (which side is up, and which is the front of the seat) should be clearly indicated.
  • A pressure relief cushion should reduce pressures at the high-risk areas for pressure sore development (commonly at ischial tuberosities and sacrum).
  • A pressure relief cushion should minimize the build-up of moisture between the cushion and the user’s skin.
  • Information should be available on how to use the cushion, how to maintain it, the expected life of the cushion, when to replace the cushion or parts of it, and any particular risks when using the cushion.
  • The cushion and cushion cover material should not cause high pressures, thereby reducing the effectiveness of the cushion in distributing pressure over the seat surface.
  • Pressure relief cushions should maintain their pressure relief properties in the climates where the cushion is expected to be used.

It is recommended that wheelchairs and cushions be evaluated based on the seating and postural support performance measures, and the results be available to the users and purchasers. The areas in which a wheelchair and cushion should be evaluated or reported on are, seating dimensions and adjustability plus cushion type and characteristics. Seating dimensions and cushion characteristics tests and reporting techniques are covered in ISO standards 7176-7 and 16840-2.

Backrest

The backrest provides users the necessary postural support. It needs to be of different heights but usually available in two sizes. Some users require more support from a backrest than others. For some users, a high backrest can reduce their ability to propel themselves effectively. Backrests may be sling or solid types with foam cushioning and upholstery.

  • The angle between the seat and the backrest (seat to back angle) should be between 80 and 100 degrees.
  • Different backrest heights should be available.
  • The backrest should support the normal curvature of the spine.
  • The middle of the back should be able to rest further back than the back of the pelvis.

Footrests

The footrest provides users with support for their feet and legs. Footrests must be individually adjusted for each user. Correctly adjusted, the footplate reduces pressure on the user’s seat and puts the user in a healthy sitting posture. Footrests may also include a calf strap and/or toe loops to keep the foot on the footplate.

Footrests need to be long or wide enough to support the foot but, at the same time, should not create difficulty while folding or moving around. Sufficient ground clearance needs to be maintained to prevent the footrest hitting obstacles or catching and tipping the wheelchair on uneven ground. The height of the footrest should be adjustable.

Armrests

Manual wheelchair armrests are only intended for temporary postural support. If needed, other postural support options should be used to keep the user’s arms free for activities such as propelling. Armrests assist in frequent pressure relief lifts and transferring into and out of the wheelchair, for example by pushing down on the armrest to lift buttocks.

Many users find it easier to transfer into and out of their wheelchair if the armrests are “low-profile” (closely following the profile of the rear wheel) or removable. In other words, armrests should be removable, folding or low-profile for easy transferral in and out of the wheelchair.

The rear wheel should be in a position that allows the user to have the best push stroke as possible and keeps the user safely balanced according to his or her skill level and ability. The position of the rear wheel should allow the user to have a good push stroke and provide the necessary stability.

Manual Wheelchair Durability 4: Wheelchair Durability

The goal of this section is to help define what makes a safe and reliable wheelchair, and how to evaluate and report these attributes to stakeholders. When a wheelchair fails, the user is not only at risk of injury but may not be able to go anywhere or do anything until the wheelchair is repaired or replaced.

Safe And Reliable Wheelchairs

Apart from ensuring that the wheelchair is safe and effective, evaluating strength and durability is a way of gathering important information that can be useful for all stakeholders – users, designers, providers, manufacturers and funding agencies. Keeping accurate records of the results of strength and durability tests will help wheelchair designs evolve so that their quality and effectiveness continually improve.

  • All wheelchairs should meet the strength, durability and safety requirements of user(s) in their own environment(s).
  • It is recommended that each country develop its own wheelchair standards to ensure a reasonable quality, for instance by using the ISO 7176 series of standards as a basis. When developing national standards, it is important to consider the weights and sizes of the users, typical use, available testing equipment and available wheelchair technology. The standards should be available to manufacturers, purchasers and users, and be reviewed from time to time.
  • All wheelchairs should be evaluated based on the strength, durability and safety requirements set by the country, and the results should be available to users and purchasers.

A wheelchair should be strong and durable enough to withstand the wear and tear placed on it by the user and to keep the user safe. Wear and tear consists of:

  • Static forces.
  • Impacts.
  • Fatigue stresses from use over time.

Simple testing can be developed to ensure strength and durability. The flammability of the wheelchair, the effectiveness of the brakes and the safety of the surfaces on the wheelchair also affect the safety of the user.

Armrests

  • Should be removable with a reasonable amount of force.
  • Should not break or bend under the user’s body weight.
  • Should not break or bend when used to lift user and wheelchair.

Backrests

  • Should not break or bend during transfers or while riding on uneven terrain.

Brakes

  • Should stop a wheelchair from sliding when on an incline.
  • Should not suddenly release while in use.

Castor Assembly

  • Castor should not fail when the castor wheel hits an object (e.g. a curb).

Footrests

  • Should fold with a reasonable amount of force.
  • Should not break or bend when used to lift user and wheelchair.
  • Should not break or bend when additional passengers or packages are loaded.
  • Should not break or bend when hitting an object such as a wall or curb.

Frames

  • Should not break or bend when used on uneven terrain.

Push Handles

  • Should not break or bend when used to lift user and wheelchair.
  • Handgrip should not slide off of push handle when user is being assisted up stairs or curb.

Rear Wheels And Axles

  • Wheels or axles should not break or bend when user goes over a normal kerb.
  • Wheels, axles and wheel-mounting hardware should not fail when user drops off kerb at angle.
  • Axles or wheel-mounting hardware should not break or bend when under typical forces.
  • Wheel spokes should not rattle or become loose.

General

  • Surfaces should not have sharp edges, sharp points or pinch points.
  • Wheelchair should not be flammable, i.e. easily combustible materials should not be used.
  • Wheelchairs should be equipped with front and rear reflecting stickers or signs for increased road safety.
  • Tipping levers should not break when assistant uses levers to tip user back.
  • Hand rim should not break or bend when it hits an object.
  • Wheelchair should not break when it falls or is dropped by handler loading or unloading it from bus or car.
  • Wheelchair should not break in normal use.

It is recommended that a wheelchair be evaluated based on the strength, durability and safety requirements, and the results be available to the users and purchasers. Static strength, impact resistance, durability and brake effectiveness tests and reporting techniques are covered in ISO standards 7176-8, 7176-3 and 7176-16.

National Testing

It is recommended that testing according to national wheelchair standards be made easily accessible to all manufacturers and providers. One method for making testing accessible is to use testing methods that are simple and inexpensive.

Fatigue Testing

Fatigue testing is critical for ensuring the reliability and safety of a wheelchair. Where fatigue testing is not possible, it is especially important to carry out well-monitored user trials and long-term follow-up to evaluate safety, reliability and durability.

Even those who do perform fatigue testing need to be aware that the testing equipment and prescribed cycles of the standards do not necessarily reflect the actual loads the wheelchair will endure over its lifetime. Monitoring the use of the wheelchair in the field will help to determine the durability and performance of the wheelchair over time.

Environmental Testing

Workshop testing does not subject wheelchairs to environmental conditions that they typically endure. Many wheelchairs fail as a consequence of dirty or worn bearings, rusty bolts or frames, etc. Therefore, long-term follow-up of users is of great importance.

User Trials

User trials are performed after workshop tests to provide feedback about the durability, effectiveness and functional performance of a wheelchair in the context and environment in which it will be used. User trials involve the selection of users who agree to use pre-production or pre-distribution wheelchairs over a given period of time. The users provide feedback at set intervals during the trial, answering specific questions about the wheelchair’s performance. Focus groups can also be used to ensure as much feedback is gained as possible.

If user trials reveal that failures are likely to occur, then design changes should be made or a different wheelchair should be found, and testing should begin again. In the case of production, if significant design changes are called for, strength and durability testing should be performed again, followed by more user trials. If only minor changes are called for, then it may be appropriate to skip the strength and durability testing and perform the user trials again.

Long-term Follow-up

After workshop and user trial testing has proven the wheelchair design is safe and effective, the wheelchair will be put into production and then sent to wheelchair services for provision. A sample of wheelchairs should be followed over time. This could be done, for instance, by contacting selected users six months, one year and three years after they received the wheelchair to determine the typical failures and maintenance requirements and their general opinion on the functional performance of the wheelchair.

Conclusions

Governments are recommended to develop and adopt national wheelchair standards to ensure a reasonable quality of wheelchairs, for instance by using the ISO 7176 series of wheelchair standards as a basis.

It is recommended that the national wheelchair standards are applicable to all wheelchairs supplied in a country, whether produced within the country or imported. General design considerations include user health and safety, strength and durability, suitability for use and production methods.

Wheelchair designs should be evaluated in three main areas: functional performance; seating and postural support; and strength, durability and safety. Results of the evaluation and testing of wheelchairs must be available to users and purchasers.

A variety of factors need to be considered when determining whether wheelchairs should be acquired through national production or importation. Wheelchairs and spare parts need to be available, accessible and affordable.

Wheelchairs should be tested by users in the context and environment in which they will be used, before they are supplied to services or users (before production or before large-scale purchase). Long-term follow-up studies should be used to ensure the wheelchair is safe and effective over longer periods of use.

Resources

  1. ISO 7176-24:2004. Wheelchairs – Part 24: Requirements and test methods for user-operated stair-climbing devices. Geneva, International Organization for Standardization, 2004 http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=31276, accessed 9 March 2008.
  2. Chan SC, Chan AP. User satisfaction, community participation and quality of life among Chinese wheelchair users with spinal cord injury: a preliminary study. Occupational Therapy International, 2007, 14:123–143.
  3. Krizack, M. The importance of user choice for cost-effective wheelchair provision in low-income countries. In: Proceedings, 12th World Congress of the International Society for Prosthetics and Orthotics, Vancouver, 29 July – 3 August 2007. Copenhagen, International Society for Prosthetics and Orthotics, 2007.
  4. Kirby RL, Ackroyd-Stolarz SA.Wheelchair safety – adverse reports to the United States Food and Drug Administration. American Journal of Physical Medicine & Rehabilitation, 1995, 74:308–312.
  5. ISO 7176-7:1998. Wheelchairs – Part 7: Measurement of seating and wheel dimensions. Geneva, International Organization for Standardization, 1998 http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=13783, accessed 9 March 2008.
  6. ISO 7176-8:1998. Wheelchairs – Part 8: Requirements and test methods for static, impact and fatigue strengths. Geneva, International Organization for Standardization, 1998 http://www.iso.org/iso/iso_catalogue/catalogue_tc/catalogue_detail.htm?csnumber=13784, accessed 9 March 2008.
  7. Armstrong W et al. Evaluation of CIR-Whirlwind Wheelchair and service provision in Afghanistan. Disability and Rehabilitation, 2007, 29:935–948.
  8. Pearlman J et al. Lower-limb prostheses and wheelchairs in low-income countries: an overview. IEEE Engineering in Medicine and Biology Magazine, 2008 (in press).
  9. Reisinger KD et al. Whirlwind Wheelchair in Afghanistan: nine-month follow-up. In: Proceedings, 12th World Congress of the International Society for Prosthetics and Orthotics, Vancouver, 29 July – 3 August 2007. Copenhagen, International Society for Prosthetics and Orthotics, 2007.
  10. World Health Organization, Guidelines on the provision of manual wheelchairs in less-resourced settings. 2. Wheelchairs – supply and distribution, 2008.

Skin Care After Spinal Cord Injury

People with spinal cord injury living life in a wheelchair are at greater risk of skin damage like pressure sore areas due to loss of feeling and reduced sensation to parts of their body. Combined with loss of muscle function, poor circulation and often poor nutrition people with spinal cord injury often develop pressure sores. Left unattended these can quickly become life threatening.

While both vulnerable, people with quadriplegia and tetraplegia are more susceptible than those with paraplegia due to the reduced capacity and strength in upper limbs to reposition or shift their body weight in a wheelchair or bed. It’s important to check skin on a daily basis in order to reduce the risk of developing problems such as pressure sores.

CLEANING AND CREAMS

Clean skin daily, dry thoroughly and avoid leaving soap residue behind as it will over dry your skin. Soaps labeled antibacterial tend to strip your skin of it’s natural acidity therein ability to fight minor infections. Avoid using to many products, talcum powders are fine if removed and reapplied daily else they may “cake up” trapping moisture in causing skin breakdown. Pay particular attention to areas where skin meets eg groin, under breasts, underarms.

Moisturizing lotions and creams keep skin supple though take care in areas where the bone is close to skin surface such as shoulders, hips, tailbone. I generally only put creams on such areas of a night as sitting on moist skin is not a good idea. Moist skin breaks down rapidly as will very dry skin. Remove any incidence of contaminants such as urine or faeces as soon as possible, these burn increasing the potential for damage. Take care cutting finger and toe nails, they are usually easier to trim when softened after soaking or shower. Don’t cut too short, I once had a carer snip the skin off the tip of my finger along with the nail. I like filing a whole lot more now.

PRESSURE SORES CAN KILL

Superman, Christopher Reeve died as a result of septicemia, blood poisoning due to a badly infected decubitus ulcer (pressure sore). I myself spent 18 months in bed with a pressure sore. Tried seaweed dressings, hydrogels, alginates, colloidial silver, pawpaw cream, emu oil, manuka honey, you name it. A store bought aloe vera gel proved most effective for me. I spent so long in bed with this damn pressure area I became very frustrated and started to rip on the one person who wanted me out of bed most, my Mum.

THE KEY TO HEALING PRESSURE AREAS

The number one best way to heal a pressure area is to stop putting pressure on it. Get off it and stay off it. When you have a burn on your hand you don’t stick it under the hot water tap again do you? Eight hours sitting on a pressure area equals eight days in bed just to get back to where you were. Once completely healed stay off the pressure area for at least another week. Then it’s vital to gradually build up your “sitting time” again. An hour a day is hard to stick to but you must if you want to get out of that bed in the long term. After a week of 1hr/day stick to 2 hours uptime/day, the following week 4hrs, 8hrs and so forth.

WHAT TO LOOK FOR

  • Reddened areas
  • Damp soft white areas
  • Rashes, pimples, blisters, bumps
  • Cuts, bruises, scrapes, scratches, insect bites
  • Hard lumps beneath the skin surface
  • Marks from seams or elastic binding
  • Dry flaky skin

Often you won’t see a pressure area until it’s too late. They can develop beneath the skin as a small pea sized cyst. If you are lucky enough to feel or notice one early do all you can to stay off it. The unlucky have seemingly fine skin one day and a weeping open sore requiring treatment and weeks of bed rest the next. Worse even they can track. Tracking happens when the cyst is unable to break through to the skin surface usually because of the constant pressure. It is forced to track a tunnel through to a skin surface where it can break through, when they do it’s bad news.

One case I’ll never forget was a room mate in hospital. Terry a paraplegic liked to drink and party spending weeks at a time 24/7 in his manual wheelchair. A cyst originating from his ischium tuberosity (bum bone) tracked and broke through on top of his thigh. They lanced the origin site and pushed sterile solutions through daily to flush out the decay. They would remove us from the room as the smell was so nauseating, I can still smell it 14 years later. Don’t let this happen guys, be vigilant and train your carers to look for these things.

PRESSURE AREA PREVENTION

Daily skin inspections as above are key along with common sense and proper use of equipment. Ordinarily we unconsciously move when uncomfortable. Without such movement blood supply is lost to the skin tissue, it begins to breakdown and die. People with spinal cord injury usually don’t have the ability to unconsciously or voluntarily move some limbs or even their entire body. Forced to sit or lay in one position for long periods cutting blood supply to the skin under pressure. Changing position will allow blood flow to return and maintain healthy cells. Doing any one or all of the below pressure changes in your wheelchair for 30-60 seconds several times daily is beneficial.

  • Pressure lifts, pushing down on armrests to lift bottom off seat
  • Leaning side to side or backwards periodically
  • Bending forward over your knees
  • Reclining the seat of your electric wheelchair
  • Having someone tilt you back in your manual wheelchair
  • Triggering spasm

Always use your wheelchair cushion, if the cover is in the wash don’t use a towel, sheepskin or anything as it takes away from the seats pressure relieving properties. Sitting on your cushion without a cover is best. In bed, body parts can be padded with pillows, sheepskin etc. to keep bony prominences free of pressure. Get into the habit of checking your body position for correct alignment and pressure-free positioning.

CORRECT POSITIONING EQUIPMENT

Use good quality equipment and ensure it fits you properly. Incorrect and poorly fitting pressure relieving equipment will obviously lead to pressure sores. An Physiotherapist or Occupational Therapist can recommend and organize the most suitable types of equipment for you. Many medical companies will allow you to trial their equipment.

CHOOSING A WHEELCHAIR

Does it support your back? Are your armrests and footrests the right height? I know quite a few people who have developed pressure blisters on their heels as a result of their foot plates being to high. Ask if it is possible to have electric tilt fitted. I’m in a Quantum Vibe at the moment, I can tilt the whole wheelchair back to 55 degrees providing good pressure relief.

JAY AND ROHO WHEELCHAIR CUSHIONS

There are two main types, air and gel. I tried an air filled Roho cushion and found the Jay2 gel cushion gives me greater stability and balance. I can sit up for 16 hours no problem. Only ever use the cover that comes with your cushion or none. Knead the gel every morning prior to sitting on it, or check the air pressure regularly. Your cushion should be replaced approx every three years before it starts to lose it’s pressure relieving ability. Many paraplegics don’t require a $900 cushion and use eggshell foam and/or a sheepskin.

PRESSURE RELIEVING MATTRESS

Are you using a pressure relieving mattress? There are many types from laytex to electric powered air mattresses. Again I’ve seen many develop heel blisters because their feet press hard against the bed end. You may be able to use an over bed triangle and you can get a material ladder like aid you hook your wrists into rung by rung and pull yourself up or help roll over. I use an Alpha Care air mattress on a laytex base electric powered bed. I can lay in one position for 16 hours no problem.

SUITABLE CATHETERS AND CLOTHING

Is the correct size catheter being used? Is it being changed frequently enough? Leg bag straps should be firm not over tight. Some run the tubing down their pants leg, as a quadriplegic I prefer it to come out the top of my pants in case I need to mess with it. Just avoid tight waistlines, pressing the tubing hard against your skin anywhere can cause blisters. Avoid seams by taking rear pockets off jeans. Be aware metal studs, zippers, buckles etc. get hot in the sun and can burn you.

SPLINTS AND BRACES

Do they fit properly? Do you do skin checks after wearing them? There is a huge range of thermoplastics and other materials for making all kinds of splints these days. If you wear splints check any bony points eg wrists ankles daily as part of your skin care routine.

HEAT

Avoid Sunburn. Don’t put plates of hot food on your lap without protection. In a car, keep feet away from the heater outlet. Place protection between feet and car floor if not wearing shoes. Check vinyl seats before sitting to make sure they aren’t too hot. Cover exposed pipes in your kitchen and bathroom sink to protect your legs from burns. Sit a safe distance from heat sources such as heaters, campfires, bbqs, fireplaces. Sweaty damp skin will break down fast, dry any sweaty or wet skin under pressure. Avoid heating pads like electric blankets.

COLD

In areas where there is extreme cold dress warmly to prevent frostbite. Dressing in layers of clothing will provide extra warmth and can be removed if need to prevent overheating. Don’t put frozen foods in your lap without protection.

FEVER

Your skin tolerances can change due to the increased body temperature that occurs with a fever. You may find that you cannot lie in one position as long. Fever is often accompanied by sweats, dry damp bony areas frequently.

BODY WEIGHT

The amount of weight a person carries not only affects the ability to do activities and health but can affect skin care. Too much – Being overweight can cause increased pressure on bony areas. Delayed healing may occur because there are fewer blood vessels in fat tissue. Too little weight can also cause problems. Excess pressure over bony areas may occur because there is less padding (muscle and fat) over these surfaces. In addition, underweight persons may lack the proper nutrition to maintain healthy skin.

SPASM AND SPASTICITY

Spasticity may cause your arms and/or legs to bump against an object, or to fall off your armrest or footrest, and be injured. Spasm are often repetitive and may also cause your skin to rub against something (for example; tight bed sheets), which can produce an open pressure area. Do all you can to prevent pressure areas in the first place as scar tissue becomes more prone to future break downs and pressure areas will continually re-occur. Did you know skin is the body’s largest organ? Take good care of it.

Kind Regards
Angi Cappelli – Occupational Therapist
Graham Streets – MSC Founder