An Ultralight FOR All Seasons

Ultralightweight manual wheelchair users who have self propelled for years and are now middle aged (or older) are true pioneers.

With today’s sleek, elegant, minimalist ultralight frames — not to mention a host of performance accessories, from in-wheel suspensions to power-assist systems — it’s easy to forget that not long ago, expectations for self-propelling wheelchair users were quite different. Fewer people survived the initial spinal cord trauma; those who did faced sharply shortened life expectancies and far less active lives.

That makes today’s ultralight users in their late 40s and older part of a new generation — the first sizable group to enter middle age and their senior years still active and, in many cases, still wanting to self propel.

In the seating and wheeled mobility community, keeping up with these consumers is an exciting and evolving challenge.

Mobility & the Aging Process

Regardless of adages such as You’re only as old as you feel, it’s true that the aging process does impact mobility in multiple ways.

“As a person ages, so does their body,” said Tricia Garven, MPT, ATP, regional clinical education manager, Permobil. “Posture and weight distribution will most likely change, and therefore wheelchair set-up (optimal configuration and seating product choices) should change with the aging person as well.”

Declines in range of motion and muscle mass are common parts of the aging process, but they can critically impact mobility in wheelchair users.

Angie Kiger, M.Ed., CTRS, ATP/SMS, clinical strategy and education manager at Sunrise Medical, mentioned a decline in range of motion in the shoulders of consumers who self propel, and how that’s especially significant for wheelchair users with quadriplegia: “Someone who’s a tetraplegic, who has limited mobility in their upper extremities with an injury around C6-C7, will [be impacted sooner] because they have less function compared to somebody who’s a true para and has full upper-extremity mobility. Our upper extremities weren’t created for us to get around on, so your shoulders do have a tendency to have rotator cuff issues and limited range that goes with it over time.”

She adds that clients who have self propelled for decades may also lack the “best practice” propulsion skills currently being taught to newly injured spinal cord patients.

Kiger has a friend who’s used an ultralight for nearly 40 years: “I’ve watched him propel his wheelchair, and it does not look a bit like what the University of Pittsburgh says is the most efficient way to propel. He’s been in my classes on how to efficiently propel a wheelchair, but he doesn’t do it. He says, “Aww, come on, you know how long I’ve been in this chair.’

“We’re a bit young in the industry when it comes to research, unfortunately. So when a lot of these long-term folks were injured or grew up in a chair, the research just didn’t exist. Those folks are hitting their 50s and 60s now.”

Changing Consumers, Changing Technology

Industry veteran Alan Ludovici, senior project engineer at Ki Mobility, is one of those longtime self-propellers now facing the aging process.

“The past five years, with age, I’ve noticed that of course, you gain weight,” he said. “Your strength goes down. I’m in my late 50s now, and I think the biggest thing is the excess weight gain, which is typical of somebody in their 50s. Your joints and muscles deteriorate as you get older. Combined with the weight, it’s extra taxing on your shoulders. Ten or 15 years ago, I was fine with my shoulders. But now, the reality is setting in for me. And I think almost everybody in a wheelchair is going to go through this process as they get older, especially in their 50s and 60s.

“The generation prior to mine, maybe people in the 1950s and 1960s, their life expectancy was much shorter after injury. Now people are living into their 50s and 60s.”

Consumers on the leading edge of this current generation have already seen one mobility revolution, said Tom Whelan, VP of product development for Ki Mobility. “Post Vietnam, you had the advent of the lightweight wheelchair,” he noted, explaining that the invention of the Quadra and other lightweight models changed technology provision for spinal cord injury patients. “Now you have this technology being developed that can change and can be fitted,” he said. “You start looking at applications.

Now, this explosion of technology facilitates an explosion of rehabilitation, which creates this explosion of inclusion, and it all feeds on itself. People are more active, they want to do more, there’s better technology, so rehabilitation changes and we’re teaching people how to use rigid-framed chairs and transfer independently and get the chairs into their cars themselves.”

One of the challenges now, Whelan said, is that while improved technology exists, not everyone knows how to apply it, including how to apply it to help aging ultralight users.

“The technology is actually still ahead,” he noted. “I talk with customers all the time who want more information on applying the technology. The want to know, for example, when to use different-diameter wheels not just for wheel access, but for mechanical advantage. Not to say there aren’t plenty of experts, but it is not universally understood. Unfortunately, a lot of the research and applicable science isn’t delivered in a way that lets them apply the technology to disability and optimize it.”

Ultralight Adjustability: What’s Possible

Ludovici gave an example of how understanding the technology and options made it possible for him to adapt after a serious incident.

“A little over two and a half years ago, I had a really bad shoulder injury,” he said. “I had torn a tendon just doing general transfers, then sat up in bed one night and completely dislocated my shoulder. I went to the hospital and woke up the next morning with an arm brace on. They said, ‘You can’t use your arm for three months.’

“Eventually, I got a power chair to roll around in for a bit, but I was determined to stay in my manual chair, so with some help, I threw together a one-arm drive and was wheeling around in that. I also used a SmartDrive [power-assist unit] for a while.”

Ludovici used his engineering knowledge, and his wheelchair sports experience, to configure his ultralightweight chair so he could use it as he recovered.

“If I get back in my chair and elevate the seat a little bit so I’m further away from the wheel, and use a smaller wheel, I can use more of my forearms and lower muscles in my arm to propel and keep some of the strain off my shoulder,” he said. “So I went down as low as a 20″ wheel, which is a kid’s wheel. But I was able to just use my wrists to propel.

“Every few months, I dropped my seat height; I started getting my wheels closer to [their previous] size, and now my shoulder is in pretty good shape. I can’t go and climb a big hill any more, but I use my power chair once or twice a year now. It took a good year and a half to get back to that point. Unfortunately, I’m driving a van now because it’s really tough to transfer. But I still can get around.”

Ever the engineer, Ludovici smiled at the one good result of that ordeal.

“Nicely enough,” he said, “it all kind of led to the one-arm drive we have today.”

Applying Those Technology Advances

Ludovici acknowledged that his experiences are not universal among users: “Some people don’t know the ergonomics, the best way to get really good propulsion out of a chair, or efficiency out of it.”

Whelan agreed: Creating the technology is only half of the equation.

“The technology exists, but the knowledge to apply the technology, as it always does, lags behind the technology,” he pointed out. “I do think that’s the onus — examining the aging process in a wheelchair and understanding the changes and what it means to the technology, and then educating. We need to be spending more time on the biomechanics of propulsion. Just as Alan said — don’t give everybody a power chair. Being able to get the properly fitted [ultralight] technology is a challenge, but that’s not the only thing you’re facing.

“Your physical structure is changing, so what does your frame need to look like? You can’t squeeze into the same seat frame, but you still need the same access to the wheels. How does seat frame design change so you’re not creating pressure at your knees — because now you’ve had to put pads on your chair to keep your knees together, because you don’t have the flexibility that you had before? Chairs can be designed for those purposes. But when do you apply it, how do you apply it?”

The same question could be asked of ergonomic and performance options, including specialized handrims, wheels and power-assist systems. Asked if such technology could be helpful to aging users, Garven said, “Most certainly, especially to aid in relief of aging-related wrist and shoulder pain, including hand/thumb arthritis. If the goal is to reduce the number of push stokes in a day, to ease the effects of overuse issues, these products can be helpful.”

Kiger pointed out that not all ergonomic options are right for every aging ultralight user — power-assist systems, she pointed out as an example, might be challenging for ultralight users with quadriplegia to assemble, disassemble and lift. “When you talk about power assist, all of the options have to be looked at. If you’re going to consider moving anybody in that direction, you should do your due diligence and let them try all of the systems, because there are unique features for all of them.”

While power-assist won’t be right for every user, “I’m a firm believer in introducing people to equipment and what’s out there,” she said. “Planting those seeds, especially if I think we’re headed down that road [of needing the technology].”

Tomorrow’s Ultralight Users

Whelan said he sees “hopeful signs” regarding the future of ultralightweight chairs for aging consumers — both in technology and in the dissemination of best practices for those users.

“I know and interact with people in the marketplace whose primary business now is not reimbursement,” he said. “They’re knowledge-based technology providers who are servicing markets where people pay for the technology. They’re selling the technology based on its merits and what it does for you. They’re not building a business for high volume. They’re building a business for high profit built on producing value around applying technology with knowledge. They’re problem solvers.

“The biggest gap is knowledge, education, training. It’s not that technology doesn’t exist. The technology is there to solve the problems. It’s just not spread evenly and being applied.”

Veteran ultralightweight wheelchair users are famous for knowing and declaring exactly what they want when it’s time to order their third or fourth chair. But that supposed knowledge can work against them as their bodies age.

“Over time, wheelchair design and technologies also advance,” Garven said. “If a person doesn’t keep up with their own changes and needs, as well as how the industry has progressed, they will most certainly not be in optional equipment 10 to 20 years later.”

Kiger agreed that mat evaluations need to happen as part of the new-chair assessment process, even with clients who just want to duplicate their old chairs.

“Are [clinicians] doing a pain scale?” she said. “Ask: When you’re propelling, what is your pain typically like? Are you truly looking at the whole gamut of mobility-related activities of daily living? They might not initially feel a twinge of pain when they start propelling, but they’ll say, ‘When I reach up in my cabinet to get the cereal in the morning, it sure does hurt.’ If their shoulders are hurting when they’re reaching up, that could manifest in other areas down the line.”

It’s worth checking, Garven added, to make sure a chair is still optimally set up to accommodate its user’s current abilities.

“One of the most important considerations for propulsion, in addition to push technique, is rear wheel access,” she said. “A great rule of thumb is to have the hub of the rear wheel near the fingertips when the arm is extended down.”

Whelan said he’s thought about education programs to cover the newly emerging topic of aging consumers who have spinal cord injuries.

“We talk about what complex rehab is, and that’s what it is to me,” Whelan said. “The complex rehab initiative is about recognizing what this industry is, and what people like Alan need, and how to apply technology. It’s a different market for full-time, life-long wheeled mobility technology users. It’s no different than for life-long amputees: My stump is diminishing in size; they get a new socket. I don’t have the same flexibility; they retune the prosthetic. It’s a constant set of changes in prosthetics, because they recognize the changes going on physiologically.

“It’s the same thing for wheeled mobility users.”

Ludovici acknowledges that his industry experience and knowledge have been critical to his independence as he’s aged. He also knows not every long-term ultralight user is as fortunate.

“The older I get, the more I need,” he said. “And the more technology I get to create. In some respects, it’s good for the industry.”