Power or Manual

Finding the Best Answer When Different Technology Choices Are the Question

• By Laurie Watanabe
• Oct 01, 2010

Every complex rehab client has a unique set of clinical needs, a prognosis, and a collection of personal goals. Customized seating& mobility springs from that highly individualized set of factors, which is never the same for any two clients.

Certain diagnoses do strongly indicate that either a power wheelchair or a self-propelled manual wheelchair would be the more logical option -- ALS, for example. But many spinal cord injury (SCI) clients have more options. And while that can be good news for patient choice, having more technology to choose from can also present more challenges to the seating & mobility team.

Starting the Assessment: Location, Location, Location?

What levels of SCI automatically preclude a client from self-propelling an ultralightweight manual chair?

Mike Babinec, OTR/L, ABDA, ATP, is Invacare Corp.'s product manager for power wheelchair electronics.

"As a general rule, the higher the injury level, the more appropriate powered mobility may be," he says. But he adds, "Outside of the obvious, where there is insufficient upper-extremity function for propelling a manual wheelchair -- C4 and above -- there is not a magic spinal cord injury level at which powered mobility automatically becomes the clear choice."

Says Jay Brislin, MSPT, director of Quantum Rehab product & clinical development: "The level of injury is definitely the first thing you're going to look at. If it's above a C5 or a C6, the person's really not going to be able to propel independently at all."

But in addition to considering the location of the injury, knowing whether it's "complete" or "incomplete" can also be helpful, Brislin says.

In SCI parlance, a complete injury describes the total loss of function below the level of injury. But a client with an incomplete injury could have, below the level of injury, "sensation, function and a little bit of strength," Brislin says. "You may still be able to find a little bit of voluntary movement."

As medical understanding and treatment of SCI continue to advance, Brislin adds, "Most of your spinal cord injuries end up being incomplete. There are a lot of procedures that allow (the client) to have a little more function. There are people who end up having strength in areas that maybe 10 or 15 years ago, they might not have had."

The caveat: Preservation of sensation, function and strength for an incomplete SCI varies greatly from client to client.

"There are some individuals who are independent in an optimally configured manual wheelchair who have an injury level of C5 -- shoulder abduction and extension, elbow flexion," Babinec says. "Yet, other individuals with an identical injury level are not independent at all with activities of daily living unless powered mobility is used."

Other Assessment Factors

Asked what other factors can contribute to a power-or-manual decision, Babinec listed an array, including:

• Ability to perform independent manual mobility in ALL required environments, accommodated and non-accommodated.
• Ability (or potential ability) to independently operate a power chair in ALL required environments.
• Co-existing disability or pathologies that infl uence today's or anticipated needs.
• Willingness to accept the appropriate mobility system.
• Ability to maintain a power chair.
• Home environmental challenges: narrow doorways, limited maneuverability for accessibility.
• Home/community barriers: steps, slopes, terrain, distance, etc.
• Community transportation needs.
• Pressure management needs.
• Postural needs.
• Transfer requirements/needs.

Brislin says another key consideration is the client’s fatigue factor.

“You may find that somebody’s able to operate a manual chair,” he says. “But you have to make sure that they’re able to from the time they wake up to the time they’re ready to go to bed — and in a functional manner. Because if they operate a manual chair for two hours, and then they’re at a point of fatigue where they can’t do mobility-related activities of daily living — then that might not be the right choice for them.”

Reassessing Long-Term Manual Chair Users

Most professionals who’ve worked with SCI clients know some who operate their manual chairs for years, even decades, without trouble. But for other SCI clients, accumulating factors can result in changes to their medical conditions and the need for reassessment.

An often-seen problem among long-term self-propellers, for instance, is repetitive strain, particularly in the shoulders, arms and hands.

Brislin says stretching and exercise are critical: “You’re getting a ton of exercise pushing that chair, but that motion is the same over and over again. Somebody’s elbows are fl exed, and they’re extending their musculature of their shoulders. By doing that repetitively, you can start to get tight in your biceps and your shoulder musculature. Stretching and exercising the muscles that you’re not using to propel the chair are really important.”

Still, for at least some self-propellers, the repetition does take a physical toll: “Overuse is eventually going to cause some sort of complication,” Brislin says. “It can be as simple as being sore — I’m sure we all have little aches and pains that we wake up with every morning.”

But for some clients, he says, overuse and repetition cause damage severe enough that full recovery is difficult: “You may see people getting surgery and evaluating whether they can continue to move forward in their manual chair, or if they need to try something else.”

In addition, the normal aging process can cause changes in client condition, Babinec says.

“Aging takes a physical toll on anyone’s body,” he explains. “Aging with a disability is no exception, and this physical toll for some can be exaggerated. In addition to the issues of aging, dependence on repetitive upper-extremity use to provide independent mobility over years’ time can lead to upperextremity pathology that not only impacts mobility, but many other activities of daily living and overall quality of life.”

Babinec also notes that cardiorespiratory dysfunction, rotator-cuff injuries, carpal tunnel syndrome, arthritis, osteoporosis, a history of pressure sores, pain and even a client’s body weight can infl uence power-ormanual-mobility decisions for long-time self-propellers.

He says the team that’s reassessing a manual chair user should therefore consider a range of functional factors, including propulsion methods, the ability to propel, transfer methods, the number of transfers needed, the types of terrain that need to be traversed, the distance that needs to be traversed, positioning systems required within the seating system of the base, and even transpor tation methods.

The Emotional Challenge of Switching to Power

If power mobility can offer improved function and quality of life for SCI clients, it might be logical to think such clients would welcome the chance to make the switch.

Not so fast.

“Change is often hard to accept regardless of the circumstances,” Babinec points out. “Changing mobility from a manual chair to a power chair is no exception. Many individuals view this as a step backward and fear becoming or being viewed as more disabled. There can be a change in lifestyle associated with this change in mobility as well, with transportation needs altered, transfer methods changed, etc.”

The decision can even be emotionally tough on newly injured clients, Brislin says. “You’re looking at an individual who was basically able to do whatever they wanted, and in a flash they become unfunctional in a lot of ways. One of the things that’s extremely important is for the clinical team to make sure they’re talking with the client and asking what they want to be able to accomplish. You may have a client who is dead set on being in a manual chair, just because they don’t want the power chair, they don’t want that ‘obstruction.’

It can be helpful to invite clients to use a power chair on a trial basis, so they can potentially experience a difference in fatigue levels or performing weight shifts via power tilt and recline. Troubleshooting can also help: If a power chair’s seat-to-floor height causes a problem at the dinner table, could the table itself be raised?

“Father Time is an excellent healer, and many need the time and space to work through these changes,” Babinec says. “Acknowledging this change for an individual as tough is certainly helpful.”

Ultimately, the more involved the client is in the decision, the better the chance that it will be accepted.

“There is a big difference in acceptance when an individual is told they must do a task differently versus experiencing the task on their own and feeling the difference it makes,” Babinec says.

Adds Brislin, “Communication is huge because the last thing you want to do is decide for them. You want to talk it through because if they’re not comfortable with what you’re doing, you’re not going to have a successful outcome.”

This article originally appeared in the SCI Handbook October 2010 issue of Mobility Management.