Basic principles

Although accessibility and wheelchair technology have changed drastically over the past 30 years, Judai’s study⁷ is a reminder that the process still is evolving. Judai used the Psychosocial Impact of Assist Device Scale to assess the psychosocial impact of assistive devices on individuals one and three months following the stroke. His findings for individuals who used wheelchairs indicated that some individuals reported a negative effect on their self-esteem, competence, and adaptability. This is a reminder to be attentive to the social and attitudinal environment that includes the stigma associated with using a wheelchair. Approaching each treatment session with a positive tone and educating individuals about the benefits of increased comfort and the potential ability to function independently indoors and outdoors are important.⁷ It is also helpful if the team has a working knowledge of community resources (i.e., support groups, transportation, and general accessibility) by which to educate the client about strategies for increased integration in the community.

Unfortunately, no specific formula exists to choosing the “right” seating system and mobility base. However, the set of guidelines discussed next can help the team achieve the best combination of mobility base and seating system with each client. The wheelchair and seating system decision is the result of an intricate interplay among an individual’s postural seated needs, personal preferences and goals, home and community environment, financial situation, and method of transportation. It is important to remember that the one-size-fits-all philosophy has no place in seating system and mobility device prescription.

The wheelchair and seating system assessment is specific to each individual’s needs. After obtaining demographic data, the assessment process generally begins at the ICF activities and participation level and progresses to the body functions and structures level. Initially, an in-depth comprehensive interview with the wheelchair team takes place to develop an understanding of an individual’s functional goals, environments he needs to function in, ability to participate in ADL, and knowledge base of wheelchair and seating system needs. The assessment then continues to screen numerous body functions such as muscle strength, balance, and cognition. This includes a mat evaluation, client education regarding postural needs and pros/cons of various seating and mobility base options, seating product and mobility product trial, and specifications of the wheelchair and seating system products. It is extremely important to take the time to perform a thorough assessment to avoid compromising the result and to minimize time spent fixing mistakes.²

Step 1: conduct a comprehensive interview

The therapist should lead the team and conduct a comprehensive interview that includes the client’s diagnosis; medical and surgical history; skin history; future medical and surgical considerations; allergies; precautions; pain; funding sources; social support network; use of splints or orthotics; previous and current level of functioning; likes and dislikes with current equipment; equipment fit in home environment, work environment, and community; transportation method(s) (car, van, taxi, or bus); and the client’s goals for the new or modified equipment. The interview should include psychosocial issues with respect to roles and lifestyle preferences; basic and instrumental ADL performance, including indoor and outdoor mobility; and transfer status. A physical status screening should take place to ascertain passive and active range of motion, available movement patterns, muscle strength, sensation, endurance, balance, visual-perception, and cognition. If the client has moderate to severe oral-motor control issues, a speech pathologist should be a member of the treatment team to ensure that the client’s communication and/or augmentative communication needs are addressed thoroughly. See Chapter 20.

If this is a client’s first wheelchair, a home evaluation form is generally provided and additional education is necessary to ensure that the client and significant others understand the environments that wheelchair maneuverability will have impact on.

Step 2: perform a supine and seated mat assessment

A mat assessment is an intimate evaluation that can be intimidating and confusing to the client and significant others. The assessment involves therapeutic handling, palpation, and range of motion. The results of the mat assessment are essential to determine the amount of support an individual requires for upright sitting, the goals and overall setup of the seating system, and the mobility base options needed to accommodate the recommended seating system. The therapist must take the time to articulate the purpose and importance of the mat evaluation to ensure that everyone “understands what you are looking for, how you will be going about it, and why this information is important to reach a good end result.”²

Before beginning a mat assessment, it is important for the therapist to understand some basic biomechanical and seating principles. One of the main concepts is the distinction between flexible, difficult to correct, and fixed postural deformities. These concepts clarify skeletal positions in the supine and seated mat assessment.

The initial focus with a mat evaluation is to determine whether neutral pelvic and trunk alignment can be achieved. If the pelvis is in an oblique position and lower extremity influence has been accommodated for or ruled out, the therapist should attempt to correct the pelvis manually.

If the pelvis stays in the corrected position, without handling, the deformity is considered flexible.¹⁹ If the pelvis goes back into the oblique position but is repositioned easily to neutral and requires gentle therapeutic handling to stay in neutral, the deformity is considered difficult to correct.¹⁹ If the pelvis cannot be repositioned manually into a neutral position, the deformity is considered fixed.¹⁹ A pelvic obliquity is measured by the height difference between each ASIS and is named for the side that is lower.¹⁹ A subsequent section discusses seating considerations for flexible, difficult to correct, and fixed body structures.

A thorough mat assessment can require two to four persons and consists of four major components:

Figure 26-5 Measurements during the mat assessment. 1, Elbow height; 2, seat to inferior angle of scapula; 3, axilla; 4, seat depth; 5, knee to heel; 6, chest width; 7, hip width.

A simulator is a tool that permits the team to evaluate a sitting client more easily with various angles and amounts of support. This simulator is composed of planar surfaces that can be adjusted to different depths, and recline, and tilt to provide appropriate support. In addition, it consists of easily adjusted components (headrest, lateral support, hip support, armrest, and footrest) that can be placed in numerous positions and are adjustable through knobs. The simulator permits therapists to evaluate the seated position with an individual, evaluate the level of function with different positions, educate the client on the potential to achieve the best possible resting posture, take more accurate measurements, visually document potential for increased alignment via pictures to funding sources, and save an enormous amount of time with evaluating different products. The simulator can help narrow the product options necessary for evaluation to provide optimal support (Fig. 26-6).

Figure 26-6 Planar Simulator.

(Courtesy of Prairie Seating Corporation.)

Step 3: provide client and team education

Educating the client about the mat evaluation findings and their effect on postural alignment in a seated position is important. At that time, the therapist can review a client’s goals, and each team member should articulate their goals to ensure that all are headed in the same direction. Education is essential to enable an individual to participate actively in the wheelchair and seating system trial and decide what compromises he or she is willing to make to maximize the ability to function in a wheelchair. Although the client is the primary decision-maker, the therapist and assistive technology supplier should freely discuss their professional opinions. Part of the educational process is to help a client prioritize what is most important, especially when future health, skin integrity, and secondary complications are a concern. There is no one wheelchair and seating system that is perfect for individuals with stroke; the solution is perfect only when a client makes informed decisions about what various components will work best for his or her lifestyle.

It is helpful to discuss wheelchair and seating system needs in a general way and then to select products so that a client can choose from two or three options. Using the mat evaluation results and understanding product features and benefits is essential and described in detail later in this chapter. The therapist and assistive technology supplier have the responsibility to clearly articulate the features, benefits, and pros and cons of various options to empower the clients to select products to best meet their needs. Providing this information empowers the client and significant others to be educated, reinforces their confidence in the decision of the team, and increases their satisfaction with the final product.

Step 4: equipment trial

Actual trial of seating system and wheelchair options is the best case scenario; however, this is not always possible. If a manufacturer is unable to provide the team members with the equipment they are considering, simulating the type of seating design and components is important for the team to ensure that the product is accomplishing what they had hoped to achieve.

Actual trial of more complex, expensive equipment is highly recommended to minimize unseen compatibility and fit problems and ensure that the full system can meet the client’s needs and goals.

Once the ideal wheelchair and seating system is decided upon, the team gathers around the client in the “evaluation” wheelchair and seating system. At this point, the team decides the measurements of the product, specifies wheelchair and seating system features with order forms, and provides additional education about the pros and cons of specific features (such as pneumatic versus solid tires). In an ideal situation, this is truly a collaborative team process.

Step 5: documentation

At this point, the therapist has gathered all the information needed to write a letter of medical necessity. This letter is a concise summary of the client’s activities and participation status, mat evaluation findings, problems with existing equipment, wheelchair and seating needs to maximize activity and participation, and medical and functional justification for the wheelchair, wheelchair features, and seating system recommendations. This is the letter that the medical doctor reviews and signs once the final additions are completed.

As the medical professionals are generating the letter of medical necessity and organizing the medical chart notes and prescriptions, the assistive technology supplier contacts each of the manufacturers for price quotes and generates a product description form. The doctor reviews and signs this form. It is sent with the letter of medical necessity and other insurance documentation to the assistive technology supplier for funding approval.

Step 6: fitting, training, and delivery

After the team has recommended and documented the person’s equipment needs, the job is only half over. It is common for funding sources to question the team’s recommendation. It is important to respond as promptly as possible to these inquiries and clearly communicate the team’s goals.

Once the assistive technology supplier feels secure that the equipment will be funded and in some cases “approved” by the funding source, the equipment is ordered. All team members who were involved in steps 1 to 5 should be available for steps 6 and 7. During fitting, training, and delivery, the wheelchair and seating system is set up and adjusted to specifically meet each client’s needs. At this time, the therapist and assistive technology supplier educate the client and significant others regarding wheelchair and seating system parts management, care, and general maintenance, including whom to contact if problems arise. For example, if a client needs replacement parts, he or she is advised to contact the assistive technology supplier; if a client experiences physical changes and is no longer comfortable, he or she is advised to contact the medical doctor and the therapist.

Mobility skills training is essential to provide clients with strategies and techniques for maximum safety and independence with mobility. This includes training for manual wheelchair operation using the traditional ipsilateral arm-foot propulsion technique,³ a one-arm drive wheelchair, or a power mobility product. Rudman and colleagues¹⁶ concluded that training was needed beyond the prescription of the wheelchair. This training is essential to provide clients with the ability to reach their full functional potential with activities and participation.

This fitting and delivery step is essential to ensure that the end product accomplishes the team’s goals and minimizes an individual’s risk for deformity and secondary problems. Another benefit to this step is that it significantly reduces the potential for product abandonment.

Step 7: functional outcome measurement and follow-up

The ideal situation would be for an individual to attend a follow-up treatment session three months after the fitting and delivery or at least to participate in a phone interview with the therapist to determine the success of the wheelchair and seating system intervention. This step is a true test to ensure achievement of the team’s goals. Follow-up should focus on issues such as whether the equipment is holding up to the individual’s specific needs and has made a difference on pain, quality of life, and independent functioning.

Barker and colleagues¹ reported that wheelchairs were an enabler of community participation. Pettersson and colleagues¹³ used the Psychosocial Impact of Assistive Devices Scale and found that wheelchairs increased quality of life for individuals after stroke.

Translating the mat evaluation into the seating system

Once the mat assessment is completed, the therapist must translate the measurements and ranges into the set-up of the seating system and wheelchair. For example, if Mr. S. has only 80 degrees of hip flexion range, the seat-to-back angle must be set up to accommodate this 10-degree limitation. Most back canes have an 8-degree bend rearward, and therefore a back support with some adjustability is provided with an additional 2 to 7 degrees of open seat-to-back angle. The extra 5 degrees is necessary to allow for some adjustment for comfort. It is important not to position an individual at the maximum range available. Likewise, if Mr. S. has hamstring tightness (−70 degrees of knee extension with his hip at 80 degrees of flexion), the therapist must be cautious about using an elevating leg rest, because it generally positions the lower extremity in −65 degrees of knee extension and would overstretch his tight hamstring musculature. Because Mr. S.’s hamstring muscle cannot sufficiently elongate to tolerate this open knee angle, his body will automatically compensate for this, which would result in Mr. S sitting with a posterior pelvic tilt. In this situation the team can order a 70-degree standard footrest and use a longer heel loop for foot position rearward for a −70- to −75-degree knee angle, being mindful of caster (front wheel) clearance. This is essential to adequately accommodate his hamstring muscle tightness and allow for optimal pelvic and spine positioning.

Flexible, difficult to correct, and fixed deformities

Once a therapist establishes what type of deformity is present, he or she must figure out how to support the client to minimize his or her risk for increased deformity. If an individual has a flexible or difficult to correct deformity, the seating system should be set up to imitate the therapeutic handling to “correct” the deformity. At this time, client education regarding repositioning strategies is helpful to ensure the client is aligned properly and to facilitate neuromuscular reeducation. It is important to carefully monitor each client’s tolerance for correction and adjust the seating system accordingly to maximize success. The process may require incremental steps to achieve increased alignment or may involve backing down from an aggressive start. If a deformity is fixed, as much aggressive support as possible is important to assist the client around his deformity to decrease progression and to minimize his or her risk for increased deformity.

With more aggressive seating systems, a mobile person can be “locked” up by the aggressive supports used to achieve optimal spinal-pelvic alignment. Unfortunately, this often limits an individual’s ability to function. With positioning for function, a compromise occurs to provide as much support as possible for the resting body position without affecting or limiting an individual’s ability to function. Consequently, wheelchair seating is a continuum with safety and maximum postural support on one end and mobility for activity and participation on the other end. An ideal seating system should have some flexibility to provide optimal spinal-pelvic alignment and facilitate function. It is important to maximize the potential movement options of individuals who use wheelchairs as their primary means of mobility. Individuals with good motor control may choose to sit on a chair or stool for more active functioning. For individuals who do not have as many mobility options available, the wheelchair must have the ability to accommodate both active and resting seated postures.

Although online resources for wheelchair and seating system products are an excellent source of information and education, online purchase of these products is not recommended because a client does not receive any of the benefits that an assistive technology supplier provides (i.e., assistance with set-up and assembly, on-site adjustments, and personalized modifications).⁹ In addition, an individual purchasing equipment online misses the opportunity for the team evaluation and product trial and may not be in-tune to mild physical changes that have occurred since last receiving a wheelchair and seating system.

General seating system principles for individuals with stroke

Therapeutic intervention for individuals with brain damage caused by a stroke depends on the severity of the infarct and the amount of functional change that has occurred, including physical, visual-perceptual, and cognitive changes. Accordingly, wheelchair and seating system intervention also depends on the level of functional changes and confounding variables, including the environment in which the individual is functioning and the presence of other diagnoses such as diabetes, hypertension, and coronary artery disease. Seating systems for individuals with more involved needs may be more supportive because of decreased plasticity in the central nervous system and permanent brain damage.⁵

Individuals with hemiplegia resulting from stroke often have difficulty controlling posture, balance reactions, and smooth movement patterns that enable the performance of functional tasks. Davies⁵ described the typical patterns of adult hemiplegia (Table 26-1).

Table 26-1 Typical Patterns of Adult Hemiplegia

For individuals who use a wheelchair as their primary means of mobility, seating and mobility recommendations should address these typical patterns of adult hemiplegia. The following are typical seating system goals and seating principles specific to individuals with stroke.

Linear seating systems

Linear seating systems (Table 26-2) are flat, noncontoured planes of support. Linear seat cushions or backs can be custom-made or ordered from the factory in various sizes, densities, and with different fabric covers.

Table 26-2 Seating Systems

SEATING COMPONENT	INDICATIONS FOR USE	POSTURAL AND FUNCTIONAL CONSIDERATIONS
Solid insert	Insert can provide a level base of support on the sling wheelchair seat. Slide insert inside the cover, under the cushion, and secure to cushion base with Velcro. The cushion cover usually has Velcro to attach the cushion securely to sling upholstery of the wheelchair.	A sling wheelchair seat encourages a posterior pelvic tilt with hip adduction and internal rotation. This sets an individual up for a “slumped” posture. A solid insert is necessary to provide a firm and level base of support on the sling wheelchair seat. This facilitates more neutral pelvic positioning for upright posture and upper body movement for functional activities.
1.5–inch seat wedge	Wedge slides inside the cushion cover, under the cushion. Wedge can provide an anterior or posterior seat tilt.	Wedge is a lightweight, easy to remove component to use for an anterior-sloped seat or a posterior-sloped seat. An anterior tilt would facilitate upright positioning for an individual who is working at a workstation or propelling with one arm and one foot. A posterior tilt can assist with decreasing extensor spasticity or creating a set, slight tilt for increased postural support in a standard wheelchair.
Solid seat	Remove wheelchair upholstery to install. To mount, solid seat hooks lock down on seat rails of wheelchair. The adjustable hooks on the solid seat can be positioned to provide an anterior or posterior tilt of solid seat and subsequently the cushion on the wheelchair frame.	Seat also encourages neutral pelvic alignment and lower extremity alignment. One concern is that it adds a significant amount of weight to the wheelchair. Unless necessary to achieve a low seat-to-floor height that cannot be achieved with a super low wheelchair, the weight disadvantage outweighs the positioning advantages.
Foam cushion	Foam linear cushions provide a stable base of support for individuals with mild postural support needs. The foam comes in varying densities and can be layered in different densities to provide support, comfort, and some pressure relief.	Cushions can enhance sitting posture, pressure distribution, and increase comfort.
Contoured foam cushion	Contoured foam cushion provides an increased surface area of support and pressure relief for individuals with mild to moderate support and pressure distribution needs. A variety of foam densities are available.	The combination of stability and pressure relief is a major advantage to this cushion. The weight is a consideration; however, the advantage of a stable and pressure-distributing base of support minimizes the need for external supports.
“Pressure-relieving” cushion (fluid medium)	A firm, contoured cushion base with pressure-distributing gel fluid pad on top provides stability and a high level of pressure relief appropriate for all individuals who need moderate to significant postural support and pressure distribution. The gel bladder allows the pelvis to sink into it for full contact support for adequate pressure distribution to minimize the risk of pressure sores.	These off-the-shelf cushions provide a superior level of pressure distribution and good pelvic stability. This stability is important for improved balance and for adequate support. It can improve function at a wheelchair level and minimize compensatory posturing.
“Pressure-relieving” cushion (air medium)	The air medium allows the seated individual to sink into this cushion for contoured support and a high degree of pressure distribution to minimize the risk of pressure ulcers.	The pressure distribution and lightweight qualities of this cushion are unsurpassed. However, this cushion does not provide any stability, and additional postural supports such as hip guides and adductors are essential for optimal alignment. These supports increase weight of the whole wheelchair system. Another concern is the continual air maintenance required with this cushion.
Lumbar-sacral back support	This component can provide support to the lumbar-sacral region to support the pelvis in neutral pelvic alignment. A more secure attachment method is recommended to keep it in position.	This support is a low-cost method to provide minimal postural support for increased spinal-pelvic alignment. The support is easy to remove, which is an advantage for car transport but a disadvantage because the support is not stable and can shift out of place easily.
Solid back support	The solid back insert provides firm support to facilitate improved postural alignment for individuals with good pelvic and trunk control. The support is easy to remove for transportability of the wheelchair and usually is attached to the wheelchair back canes with Velcro straps.	This support is a low-cost method to provide minimal postural support for increased spinal-pelvic alignment. The support is easy to remove, which is an advantage for car transport but a disadvantage because the support is not stable and can shift out of place easily.
Pita back	This solid back insert provides a firm support to facilitate improved postural alignment for individuals with good pelvic and trunk control. The support is easy to remove for transportability of the wheelchair and slides into and out of a pocket in the back support upholstery.	This simple, low-cost back support can provide minimal postural support for increased spinal-pelvic alignment. The lack of foam makes the support easy to use; however, lack of sufficient padding is a concern for individuals using the wheelchair as a primary means of mobility.
Linear back support	This solid back insert provides a more durable back support for increased spinal-pelvic alignment. It is beneficial for individuals with good postural control, is attached to the wheelchair frame with quick-release hardware, and usually is linear with a solid posterior base with foam in front. The support may be covered in vinyl or other materials.	This is a planar back support to enhance upright sitting. The adjustable mounting brackets makes it possible to open up seat-to-back angle to accommodate a hip range of motion limitation or for increased postural support and balance via gravity. This hardware is durable. One concern is the weight added to the wheelchair.
Adjustable-angle off-the-shelf back support	This back support can be attached to the wheelchair with quick-release hardware. The support has generic, gentle contours that provide a guide for increased postural alignment for individuals with mild to moderate positioning needs and can be used in its original configuration or can accommodate a contoured foam in-place back support.	This back support provides mild contour to facilitate neutral trunk posturing and increased spinal-pelvic alignment. The angle can be adjusted to open up seat-to-back angle to accommodate a hip range of motion limitation or for increased postural support and balance via gravity. This support is a lightweight option that provides good support. One concern is that more durable hardware may be necessary for individuals with significant spasticity.
Adjustable-angle custom back support	This rigid back support can be attached to the wheelchair with quick-release or stationary hardware. The support often is positioned at an angle with a custom-contoured amount of support. The shell can be reused if the foam insert needs to be modified. This support benefits individuals with moderate to significant trunk weaknesses and/or flexible or fixed postural deformities.	This back support can provide moderate to significant support for individuals with flexible and fixed deformities. The hardware can open up the seat-to-back angle for the foregoing reasons. The contoured support provides maximum surface area contact to maximize alignment, accommodate deformities, and maximize pressure distribution to minimize the risk for increased deformities and pressure sores.
Pelvic positioning belt	Pelvic belts are designed to maintain optimal pelvic alignment and minimize an individual’s risk for sliding out of the wheelchair. They are mounted to the seat frame via screws or straps and are available with various angles of pull and various buckles such as auto and airline style.	This support can be positioned at various angles depending on the individual’s needs and functional level. A pelvic belt at the traditional 45 degrees can limit pelvic mobility for an anterior weight shift for forward reach and functioning at a table. Padded belts are available to minimize pressure concerns, and various buckles are available for maximum independence with opening/closing.
Leg adductors	A leg adductor can be attached to the wheelchair cushion base, under the seat, or on the footrest hanger and is designed to maximize lower extremity alignment and prevent the legs from rolling into abduction or external hip rotation. This is an example of an adductor added to the front of the cushion.	Adductors can facilitate increased lower extremity alignment to minimize an individual’s risk of increased deformity and pain. The height of the adductor can limit side-to-side transfers; a removable one can provide adequate support and increased safety with side transfers.
Hip guides	Hip guides provide support to maximize pelvic alignment, can be contoured or linear, and usually are made of different density foams with a solid back. Hip guides can be mounted onto the wheelchair armrests, seat pan, or back canes. The hardware can be fixed or removable. This is an example of hip guides that are attached to the rear of the cushion.	In addition to the lateral supports, hip guides can provide a third point of control for individuals with fixed or flexible spinal curves or individuals who have a pelvic obliquity. Removable hardware is often necessary for individuals who perform side-to-side transfers.
Medial knee block (pommel) with flip-down hardware	Medial knee blocks or pommels can maximize lower extremity alignment. They are designed to minimize leg adduction and internal hip rotation. For optimal support the medial knee blocks are custom-made in a variety of shapes and sizes. This contour is essential for adequate contour and fit for increased pelvic and lower extremity alignment. The knee blocks and pommels typically are constructed of a variety of foams with a solid inner component and are attached to the wheelchair with various types of hardware.	Medial knee blocks are often necessary for individuals with severe adductor spasticity. They are most successful when used with the other postural supports to maximize overall postural alignment. They can promote increased lower extremity alignment. Small medial knee blocks are helpful as a guide for more neutral lower extremity posturing.
Pelvic obliquity build-up	This component is usually mounted under the gel pad or created with foam; it can be a gel or foam medium and can provide increased support under the lower ischium to “correct” a deformity, under the weaker side to accommodate for muscle atrophy, or under the higher ischium to accommodate a deformity. This component may be used with hip guides to minimize lateral tilting of the pelvis for increased spinal-pelvic alignment.	Foam or gel inserts are helpful for individuals with asymmetrical muscle strength. They can compensate for the decreased muscle bulk to facilitate a more level pelvic position. When used with hip guides, inserts can support optimal pelvic alignment in individuals who have a flexible pelvis. One concern is the amount of pressure the inserts place on the ipsilateral ischial tuberosity.17 Monitoring of pressure with this treatment approach is important. If a pelvic obliquity is fixed, positioning an insert under the higher side is necessary. This will accommodate and support the fixed pelvic obliquity, increase pressure distribution, and minimize the risk of increased deformity.
Lateral trunk supports, straight and curved	These supports usually are mounted off the back support or back canes and are available in various sizes in planar or contoured levels of support. They are beneficial for individuals with trunk weakness or a tendency to lean to one side. Another point of control, usually via hip guides, is necessary for adequate trunk support to correct a flexible deformity or accommodate a fixed deformity. The hardware to mount to the wheelchair can be stationary or quick release.	Individuals who have decreased trunk support often hold themselves upright with their upper extremities. Lateral supports can provide increased trunk support to these individuals so that they can use their extremities for bilateral upper extremity tasks. Lateral supports also can provide the upper two points of control to correct or accommodate a lateral spinal curve for increased midline positioning of the torso in the wheelchair. The swing-away hardware is helpful to position the lateral support out of the way for transfers, dressing, and initial positioning in the wheelchair. Lateral support hardware that aggressively contours to the back support contour is necessary to keep the hardware profile minimal to allow for adequate upper extremity mobility. Curved lateral support pads provide improved contour and support over planar lateral support pads.
Harness/anterior chest support	Anterior chest supports are mounted to the wheelchair via four points of attachment, usually to each side of the back support and the seat rails. They are available in a variety of styles and are beneficial for individuals with severe trunk weakness. These supports often are used with a tilt or recline seating system to maximize postural support when an individual is more upright against gravity.	This component can provide anterior trunk support to allow an individual with poor trunk control to be more upright against gravity. This is helpful for more dynamic, engaging activities (i.e., working at a desk). Therapists should consider this component after evaluating a recline or tilt-in-space seating system for increased postural support in a more sedentary, posterior position. The component can be helpful for maximum trunk support for increased safety and stability when negotiating varying terrain (i.e., ramps and door saddles).
Head/neck support	Head/neck supports can be mounted to the back support via quick-release or flip down hardware. A headrest and/or neck support is essential to provide adequate head support for individuals with poor head or neck control. The quick release and flip down hardware is necessary to maneuver the headrest out of the way for positioning the client in the wheelchair, hair washing, etc.	This component is necessary for individuals with fair head control and for head and neck support when an individual tilts back for pressure relief or improved postural support. Additional pads and head bands are available for individuals with significant head positioning needs. The head and neck supports should be adjusted to support the head in as neutral alignment as possible for optimal functioning (i.e., respiration and feeding) and speech.
Wheel lock extension	Wheel lock extensions can be mounted over the existing wheel lock handle. They are available in various sizes. Wheel lock extensions provide a longer lever arm to make it possible to access and lock/unlock the wheel locks if an individual cannot negotiate the standard wheel lock.	Extensions are important for maximum independence and to stabilize the wheelchair for functioning and safety with transfers to and from the wheelchair. For individuals with stroke, a wheel lock extension on the wheel on the client’s weaker side is often very helpful for independent use with either the weaker or the stronger upper extremity.
Upper extremity support, full and half lap trays	Lap trays can be mounted over the armpad with “slide” hardware with an additional strap for stability, if necessary. They come in full or half tray models in various sizes. They can provide individuals with a support surface for their paretic upper extremity.	Adequate upper extremity support is essential to minimize an individual’s risk for increased shoulder pain and deformity. A lap tray can provide a work surface for functional activities such as writing and feeding. The clear version can also provide an individual with a clear view of the feet for maximum safety with wheelchair propulsion. Upper extremity edema is often present in individuals who are unable to move their upper extremity functionally. A lap tray can facilitate increased awareness of this extremity for edema management, weight-bearing, and positioning to minimize upper extremity edema.
Arm trough	An arm trough can be mounted on the standard armrest in place of the armpad. The trough can provide more aggressive support for adequate upper extremity joint protection. Full length armrests are often necessary to provide sufficient stability for an arm trough.	An arm trough provides optimal support for individuals with absent to poor upper extremity control. Support is important to minimize the risk for pain, subluxation, and edema. An arm trough can provide an individual with a surface for upper extremity weight-bearing for functional reaching activities or for repositioning his/her body in the wheelchair.

Linear seating provides a firm, rigid seating base that can be beneficial for active individuals. Individuals with minimal musculoskeletal involvement typically benefit the most from linear seating. This seating is generally a lower cost option, and because of the flat surface, independent transfers are easy to achieve. Linear seating systems provide the least amount of postural support; however, because the human body is contoured, lack of support can result in higher peak pressures and pressure ulcers for individuals with prominent bony structures.

Contoured seating options

Contoured seating system options (see Table 26-2) are designed to support the body ergonomically. They are generally available in predetermined shapes of varying contours in a wide range of sizes.

Contoured seating options provide a range of contours from mild to aggressive. This type of seating system provides an excellent surface area for support that can enhance postural alignment and pressure relief. Individuals with minimal neuromuscular or central nervous system insults can benefit from the gentle cues that the slight contours of this seating system provide. Individuals can also achieve independent transfers with the mild contour options.

Individuals with moderate impairments benefit more from moderately contoured seating systems. These individuals are less likely to perform independent transfers, and the increased contours can meet their more involved postural support and pressure distribution needs. An advantage to an off-the-shelf contoured seating system is that it can be modified as an individual’s needs change. It is important to remember that more aggressive contoured supports really hold and support an individual, which is ideal for postural alignment but can make transfers more difficult.

Custom seating options

Custom seat cushions and backs provide adapted support to meet an individual’s specific needs. Customized seating systems are essential to provide maximum support, accommodation, and comfort for individuals with moderate to severe deformities. The concerns with custom-molded seating systems is the lack of flexibility for changing postural support needs, the high cost, and the amount of labor to create a customized seating system. An experienced therapist and assistive technology supplier is essential to achieve a successful end product with this level of seating system.

In addition to the primary support surface contours, the angles and degree of postural support from gravity are major considerations. Two dynamic seating system options available are recline and tilt-in-space seating systems. Both of these systems can position a person posterior from the upright, 90-degree sitting for postural support from gravity. A recline seating system is one in which the back support can be shifted backward or forward for varying levels of support and upright posture (Fig. 26-7). A tilt-in-space seating system is one in which the whole seating system (cushion and back support) tilts backward for increased postural support from gravity. Both of these systems can provide individuals with increased postural support and a method of pressure distribution through movement of the seating system. A recliner or a tilt-in-space wheelchair is often beneficial for individuals who need moderate to maximal support for upright sitting. These seating system options are available in both manual and power wheelchairs. With a manual seating system, a caregiver is essential to perform the movement. A power-operated seating system can provide an individual in the wheelchair with the ability to shift position independently for pressure distribution, increase postural support due to fatigue, decrease postural support for more upright seated functioning (i.e., feeding), or meet varying environmental demands (i.e., increased recline for improved support when descending a ramp).

Figure 26-7 Recline versus tilt options.

The concept of reclining the back of the seating system or slightly tilting the seating system can be performed in 5- to 15-degree ranges in a standard wheelchair through add-on back supports and/or seat wedges. This is often necessary to accommodate hip range limitations or provide an individual with improved postural support and balance to function upright against gravity. One consideration is that this is a fixed, stationary position in a standard wheelchair. The stability of a recliner or tilt-in-space wheelchair that is specifically designed for tilt or recline is essential for this position to be a dynamic seating function.

Table 26-2 describes a variety of seating system products and secondary support products for seating systems and depicts the seating component, its indications for use, considerations for use, and the functional benefit.

Unilateral neglect

Depending on the stroke, some clients present with unilateral neglect at the body structures and function level. This leads to significant challenges with activities and participation. Several studies investigated unilateral neglect and mobility including wheelchair mobility. Qiang and colleagues¹⁵ used a wheelchair collision test to assess behavioral unilateral neglect. Their investigation found high test-retest reliability with this as a simple screening test for unilateral neglect.

In addition to the test, several studies investigated the effect of unilateral neglect on mobility. Turton and colleagues¹⁸ found that differences in environmental navigation were dependant on their mobility product use. They found that subjects with left side neglect tended to drift to the left with wheelchair use. However, two of the same clients consistently drifted to the opposite side, the right side, when they ambulated. Punt and colleagues¹⁴ found that differences in subject’s mobility tendencies with drifting to the ipsilesional versus contralesional side were dependant on the environment. In open spaces, the clients with neglect tended to drift toward the ipsilesional side, and in tighter spaces. clients with neglect tended to drift toward the contralesional side. Both of these studies^14,18 have implications in training individuals with neglect for safe mobility using both manual and power wheelchairs. See Chapters 18 and 19.

Manual wheelchair frame styles

Two basic types of manual wheelchair frame styles are available: rigid and folding. Rigid wheelchairs tend to be lighter weight and more maneuverable than their folding counterparts. This is because of fewer moving parts and a shorter base length resulting from the integrated footrest design. Folding wheelchairs are designed with a cross brace that allows the chair to fold in half for transport and storage. The wheelchair style commonly recommended for individuals with stroke is the folding style, which is because the style is traditional and most familiar to medical professionals, can be folded up to store in the corner, fits into certain reimbursement codes, and is recognized easily by the general public.

An individual’s medical condition, functional status, seating system support needs, home environment, method of community mobility, and funding source are important variables that influence the style of wheelchair frame recommended. Wheelchair frames are made of different materials to meet various chair weight requirements. The weight of the wheelchair is important if the person’s strength, endurance, and propulsion abilities are in question. A basic wheelchair is constructed of aluminum, is relatively heavy, and is appropriate for persons who are not active and do not use a wheelchair as their primary means of mobility. These wheelchairs are durable enough for light everyday use and are reasonably priced. Ultra-lightweight wheelchair frames typically are constructed with aircraft aluminum or titanium and are durable but more costly than standard wheelchairs. In general, these wheelchairs are not typically recommended for individuals with stroke, even for individuals who will use a wheelchair for their primary means of mobility. There are many thoughts on why this better quality wheelchair is not recommended, which include the wheelchair code that the principal funding source Medicare has for this level wheelchair and the documentation necessary for this level of wheelchair.

Because of the increased incidence of repetitive stress injuries in individuals who use wheelchairs as their primary method of mobility, a strong case can be made for justification of an ultra-lightweight wheelchair for individuals who have sustained a stroke. For individuals with hemiplegia, trunk weakness and use of one upper extremity for all mobility, transfers, and ADL performance is of great concern. A study by Cowan and colleagues⁴ focused on novice older adults and found that a more anterior axle position decreased the forces necessary to propel the wheelchair, especially on everyday surfaces such as carpets and ramps. This author feels these results support the use of an ultra-lightweight wheelchair for mobility. Ultra-lightweight wheelchairs typically have an adjustable axle that can be adjusted lower for increased trunk balance and slightly forward for a different center of gravity and an optimal hand-to-wheel relationship. This adjustment can decrease the mechanical forces required for wheelchair propulsion and is essential for energy conservation and adequate joint protection of the upper extremity. For the same reasons, power mobility can be considered as a viable option to preserve upper extremity function and maximize overall functioning and community mobility for individuals who have sustained a stroke.

Fig. 26-9 shows the basic wheelchair frame style. Consideration of frame style, wheelchair accessories, and the seating system is crucial to ensure adequate postural support and maximum function at a wheelchair level.

Figure 26-9 Basic style of wheelchair frame.

The following are wheelchair and wheelchair frame features that are important to consider when recommending a folding manual wheelchair.

Wheelchair frame seat-to-floor height

Three common seat-to-floor heights are these (Fig. 26-10):

Standard: 19.5 inches from seat to floor

Hemi height: 17.5 inches from seat to floor

Super low: 14.5 inches from seat to floor

Figure 26-10 Wheelchair seat-to-floor height differences.

The seat-to-floor height is the height from the floor to the sling seat of the wheelchair. It is important to remember that the height of the cushion chosen also influences the seat-to-floor height. The wheelchair frame height decision is based on the individual’s lower extremity knee-to-heel measurement and what type of wheelchair propulsion the client uses.

If an individual pushes the wheelchair with both arms or is not independently propelling the wheelchair, the footrest clearance is a major concern. After the client is positioned with good femoral support on the wheelchair cushion, approximately 3 inches of clearance should be between the footplate and the ground. This is essential so that the client can negotiate ramps and uneven surfaces without scraping the footplates on the ground. This seat-to-floor height is often compromised to 2 inches of clearance to allow for improved table and desk access.

If an individual is negotiating the wheelchair with one arm and one foot, then the seat-to-floor height is crucial for comfort of the hemiparetic lower extremity on the foot rest and adequate heel access for propulsion of the wheelchair with one or both lower extremities.³ The individual’s knee-to-heel measurement (taken with shoe on) is generally the exact measurement from the top of the wheelchair cushion to the floor. The wheelchair should not be too high because the client will slide into a posterior pelvic tilt to obtain improved heel contact for efficient mobility.³

Wheel handrims and one-arm drive wheelchairs.

Handrims are the circumferential rim on the outside of the tire to allow stroking and propulsion of the wheel. Hand rims are available in aluminum, plastic-coated, or projection styles. One-arm drive wheelchairs have two hand rims on one wheel only (Fig. 26-11).

Figure 26-11 One-arm drive wheelchairs have two hand rims on one wheel only.

The team should consider the following options:

Aluminum or composite hand rims are standard on most wheelchairs. Aluminum hand rims can become slippery or cold in different weather conditions. As a result, most active wheelchair users wear specific gloves to compensate for this.

Plastic-coated hand rims are beneficial for individuals with decreased grasp. The plastic coating provides traction against an individual’s hand or a Dycem glove. The one disadvantage is that individuals cannot let the rim run through their hands as they descend hills and ramps because the friction will burn the skin on their hands.

Projection handrims are occasionally used for individuals with decreased grasp. The disadvantages are that they can increase the overall width of the wheelchair if they are not vertical and the propulsion method is more labor intensive because one has to look continually at the handrim to hit the projection.

One-arm drive wheelchairs have right- and left-hand rims on the same side. This wheelchair was designed for individuals with only one functional upper extremity (see Fig. 26-11). The double hand rim allows one upper extremity to control the wheelchair in all directions. Use of these wheelchairs takes much strength and a high degree of coordination to move straight. In addition, this propulsion method has a longer learning curve because the concept is difficult to master. Mandy and colleagues¹¹ documented the inefficiency of mobility using a one-arm drive wheelchair and investigated an ankle controlled prototype product to increased efficiency with manual wheelchair use. This product demonstrated promising potential for increased efficiency with mobility in a manual wheelchair. However, it is still in the prototype phase and not readily available for purchase at this time. Unfortunately, unilateral hand-foot propulsion or a one-arm drive propulsion style are the only options available for individuals with hemiplegia at this time. Asking an individual to use his or her one functional upper extremity for wheelchair propulsion is an excessive request if one considers that the client also uses this one extremity for all other ADL. The study by Barker colleagues¹ study supports this and found the effort to mobilize a manual wheelchair was a contextual barrier for activities and participation. This study supports the concept that a power wheelchair should be strongly considered for independent mobility along with adequate upper extremity joint protection and energy conservation. The increased community participation with power mobility is supported in studies performed by Barker and colleagues¹ and Pettersson and colleagues.¹³

Elevating leg rests and footrests.

Elevating leg rests can raise or lower the lower extremities if an individual requires this because of a medical condition (Fig. 26-12). Footrests have a fixed knee angle and support the lower extremity in sitting.

Figure 26-12 Elevating leg rests raise or lower the lower extremities.

The team should consider the following:

Elevating leg rests typically are recommended for individuals with limited knee angles (because of arthritis or other orthopedic diagnosis), poor circulation in the lower extremities, or edema. These leg rests typically are overprescribed and should be considered carefully. An elevating leg rest usually protrudes out farther than a footrest. This increases the overall length of the wheelchair and compromises maneuverability. If an individual does not have adequate hamstring muscle elongation to tolerate this large knee angle change, he or she will sit with a posterior pelvic tilt to compensate for the lack of muscle flexibility (Fig. 26-13).⁹

The circulation benefits of these leg rests are questionable, since they do not raise the lower extremity above the heart in a standard wheelchair.

A major disadvantage to elevating leg rests is the significant amount of weight they add to the wheelchair.

Footrests are available in different knee angles, typically 60, 70, and 75 degrees. The angle recommended should be based on the individual’s knee range and hamstring range from the mat evaluation. Proper adjustment of the footrest length is important to ensure lower extremity stability and support in sitting. Swing-away removable footrests enable the footrests to be shifted out of the way for increased safety with transfers and improved table accessibility.

A 70-degree angle is usually a standard option and provides a shorter turning radius than a wheelchair with the 60-degree angle footrest.

Figure 26-13 Effect of shortened hamstrings on pelvic positioning.

Power mobility products

Barker and colleagues¹ studied stroke survivors and wheelchair use. They found that a manual wheelchair was actually a contextual barrier for individuals with stroke and power wheelchair use enabled community participation. Studies by Makino and colleagues¹⁰ and Mandy and colleagues¹¹ also documented the inefficiency of mobility using current techniques and products (a one-arm drive wheelchair and ipsilateral hand/foot propulsion technique) and investigated different prototype products to increased efficiency with manual wheelchair use. There have been several products developed that show promising potential for increased efficiency with mobility in a manual wheelchair.^10,11 However, these products are in the prototype phase, are not necessarily practical for daily use, and are not readily available for purchase at this time. As a result, power mobility appears to be an enabling option for individuals with denser hemiplegia.

Power mobility products frequently are recommended for individuals who do not have the strength, endurance, or coordination to negotiate a wheelchair manually. Power mobility can provide individuals with increased independent and safe mobility within the home and the community. This mobility is essential to provide individuals with increased ability to perform ADL and to perform their life roles. At this time, it is important to note that clients need to present with a basic level of visual-perceptual and cognitive functioning and be available for power wheelchair mobility skills training for a power wheelchair to be a safe method of mobility. The wheelchair industry has progressed significantly in the past 20 years; consequently, a wide array of products now exist to meet the most challenging physical needs. This section gives an overview of power mobility products with a general list of considerations for each option.

Power scooters

Scooters provide individuals who have good balance and upper extremity control with a means of power mobility. They are available in three- or four-wheel bases (Fig. 26-14). Scooters have a long and narrow base, and as a result, they are great for open areas and general outdoor community mobility. They can be disassembled for car transport; however, this is an awkward task to perform and may present an injury risk for the caregiver.

Figure 26-14 Clients are appropriate for power scooters if they have good functional control of their upper extremities, trunk control, and appropriate visual, perceptual, and cognitive skills.

The team should consider the following:

Basic power wheelchair

A basic power wheelchair is durable and can handle relatively level terrain. Most basic power wheelchairs operate by joystick. The joystick controls the speed and direction of the wheelchair. Some basic power wheelchairs can even be folded for car transport.

The team should consider the following: