Complex Rehab Technology (CRT) is defined by individualized configuration: Every seating and wheeled mobility system fits one person only.
The owner of that system is also unique — not just in personal goals and function, but also in how well and how fully that person uses that device. For every rider who casually pops wheelies to get over a curb — indeed, defying gravity — there is another rider who doesn’t know how … or where to start.
Everyday wheelchair skills — managing ramps, curbs, doorways, transfers, etc. — are essential to accessing the world. And successful skills all start with wheelchair setup.
Configuration is critical to wheelchair skills success
Leslie Wade, MOT, OTR/L, ATP, regional clinical education manager, Permobil Americas, said, “Learning to navigate an ultralight wheelchair can be a transformative journey, enhancing mobility, independence, and confidence. Whether you are a beginner starting with basic wheelchair skills, intermediate, or an advanced user, mastering these skills can open up a world of possibilities. The first step is to provide the rider with an optimally configured ultralightweight wheelchair with an appropriate seating system.”
Michelle L. Lange, OTR/L, ATP/SMS, Access to Independence Inc., concurred. “I think it’s really important to say that there are so many factors that impact someone being successful in their mobility,” she said. “So sometimes someone will jump right into ‘I have to train you on a certain skill,’ but doesn’t realize that the person may not be successful because of other factors that haven’t been addressed yet. Some of them are really basic: If you’re not positioned well in your seat, you’re not going to use your mobility device optimally, whether it’s a manual chair or power chair. If it’s a manual chair and it’s not configured right, you can try to teach someone how to do a wheelie all day long, but they’re not going to be able to find that sweet spot.”
Lauren Rosen, PT, MPT, MSMS, ATP/SMS, program coordinator at the Motion Analysis Center, St. Joseph’s Children’s Hospital of Tampa (Fla.), has long used the “Cheetos” metaphor to describe what too frequently happens when an ultralightweight chair isn’t optimally configured for a pediatric client.
“When I start with the little ones, I talk to their parents about how we’re putting as little on the chair as possible to make them functional,” she said. “If I need a back with laterals, it’s on there, because I want the kid to be able to function. But I’m putting as little as I can to get the kid to where they need to be. I’m not ‘diagnosis seating,’ which is ‘You have spina bifida, so you need this chair with every piece of positioning equipment known to man.’ The wheels are way too far back, so you couldn’t pop a wheelie if you tried.”
Over time, that heavy, hard-to-maneuver chair can impact the child’s activity level. “I use the reference all the time that if my chair is hard to push, I’m not going to go outside and chase my friends around and play in the driveway,” Rosen said. “I’m going sit on the couch and eat Cheetos.”
As for power chairs, “Sometimes, rather small changes can really make a difference in this person being successful or safer in their mobility,” Lange said. “It’s also about how the chair is programmed — because someone may not be doing well navigating their environment because the chair is poorly programmed. You can program a chair well, but you can program it really badly to where it’s unsafe, where it’s practically undrivable.”
Identifying priority skills
When there are so many skills to learn — and in today’s rehab model, so little time for clinicians to teach them — what skills should seating teams prioritize?
For self-propellers, Wade said, “You start with basic wheelchair skills, such as proper pushing techniques, transfers and turning. Learning efficient pushing techniques in a properly fitted ultralightweight manual wheelchair will help reduce the risk of shoulder strain and maximize propulsion.
Starting indoors on a flat smooth surface is easiest and allows the rider to focus on the technique. Learning how to maneuver in tight spaces such as bathrooms, elevators, and through narrow spaces in the community is critical for independence in daily activities.
“Safe transfers to and from the wheelchair is another basic skill that is typically taught early on. Whether the rider is doing a stand pivot, squat pivot or using equipment such as a transfer board or caregiver assistance with a lift, a safe transfer is essential for independence. As the wheelchair rider learns these basic skills, they are gaining confidence and learning their balance to help move to more intermediate skills such as wheelies, pop-ups, and propelling over various surfaces like grass, carpet, and gravel. Different surfaces require different techniques.”
For power chair riders, Lange said, just driving the chair efficiently can be a challenge.
“It’s still amazing to me that tracking technologies are an optional feature,” she said. “Tracking is often not recommended, and is particularly important if this is someone who’s driving outside a lot. They’re going down a sidewalk, and they keep hitting those driveways, and they don’t have tracking technology. It’s up to the driver to keep compensating for that with the joystick or with their alternative driving method.”
Tracking technology “helps that chair stay on course. So if I’m giving a forward command, I can go all the way down the street, and even if I’m hitting some bumps in the road, I’m going to pretty much hold that forward course. I don’t have to compensate for all those environmental barriers. But the team has to remember that. Someone around that table has to say, ‘Let’s add on tracking technologies,’ because it’s typically not standard.”
Preparing for ‘oops’ moments
Rather than ultralight wheelchair riders living in fear of challenging scenarios, Rosen advocates for teaching skills ahead of time.
“It used to be, when I first started in this business, that you didn’t leave rehab till you could do a curb,” she said of spinal cord injury (SCI) clients. “You didn’t leave rehab till you could upright your wheelchair. We had all these skills that you had to be able to do.”
That was back in the days when SCI patients stayed in rehab hospitals for longer periods. Today, SCI patients are discharged much more quickly, often at the expense of learning the skills they’ll need going forward.
“You used to have to be able to get yourself, if you spilled out of your chair, back into the chair and turn your chair right side up if it flipped,” Rosen said. “If you fell back in your chair and you were still in the chair, you could upright the wheelchair. If your legs are still hanging underneath it, and you’re looking up at the sky, and your butt is still basically in the chair, you can upright the wheelchair if you’re a para[plegic].
“You have to have really strong abs. But I would teach our patients how to do that. Not all of them left being able to do it, but I showed them that you could do it, that this was one way to get up if you get on the floor. We also talked about falling free of your chair, putting it upright, and how to get in it from the front if you needed to. We taught both ways.”
And of course, learning to pop a wheelie is a must.
“Within reason, I can pop a wheelie in just about any chair I sit in because I can find the balance point really quickly,” Rosen said. “I know how to find it because I’ve felt it with enough chairs that I just know.”
When demonstrating to new ultralight riders and their families, “I show them how little force and how little effort it takes for me to get there, and what that’s supposed to look like, and what that’s supposed to feel like,” Rosen added. Even if it’s possible to wheelie with anti-tip bars in place, “I want them to get rid of the tip bars,” Rosen said. “I want those to go eventually because in some cases, they do get in the way. They make the chair larger when you’re putting it into a vehicle. So if they can function without them, I would prefer to function without them.”
And — after finding a soft patch of grass to practice on — Rosen has taught clients how to fall. “You’ve got one hand behind your head and one hand over your knees. Because if you’re a para[plegic] or a quad[riplegic] who has no function in your legs, if you flip and you don’t put your arm there, you’re going to break your nose with your knee. I was always told to teach people how to fall with one hand behind the head so you don’t hit your head on the ground, and one hand is blocking the knees.”
That patch of soft grass is also a great place to practice wheelies “because you’ve got more surface area contacting the ground than you do on a hard surface,” Rosen added. “That makes it easier to catch it, because you’ve got more grasp with the surface. And also if you do fall, it’s grass — not as bad.”
The clinician or other volunteer acts as the “spotter,” whose job it is to prevent falling during wheelie practice, and who brings along a gait belt or similar device. “You wrap it around the towel bar on the back of the chair, you keep it slack, and they learn to throw the wheelie and find [balance]. You’re standing right behind them, and you’ve got the belt when they’re coming back. If they go too far, they land on your arm, and you pull the belt, and you get them upright without them actually doing the full flip. That was taught to me when I was in PT school.”
Don’t overlook the chance for riders to learn from each other. “Connecting patients with peer mentors who have successfully mastered wheelchair skills can provide motivation, practical tips, and the opportunity for sharing experiences,” Wade said. “I have witnessed the positive impact of peer learning firsthand! Seeing my patients relate to and learn from their peers can be incredibly powerful. When a wheelchair rider embraces the opportunity to enhance their mobility, they can take control of their journey.”
Learning skills for a lifetime
While seating specialists might teach their clients the ideal ways to perform wheelchair skills, clients are likely to adapt those skills to best fit their everyday lives.
“I teach you how to transfer when you’re in rehab,” Rosen acknowledged. “But if I look at your transfer a year later, it doesn’t look like how I taught you. You figure out your own technique.”
And even those techniques will change over time.
“As we age, our bodies and abilities change, and the need for wheelchair skills can change as the rider ages and/or their condition progresses,” Wade said. “As riders get older, they may benefit from learning additional or different skills to adapt to their physically changing needs and maintain their independence, health, safety, psychological and social well-being.
“Riders may experience a change in their endurance, strength, and joint integrity. They may develop pain or postural changes that lead to needing new techniques for propulsion or innovative technology such as a power-assist device for their ultralight wheelchair. Or they may need to switch to a power wheelchair and learn all-new wheelchair skills.”
You have to keep up with mobility training,” Lange said. “You have to revisit with that person as their equipment changes and their abilities change and their cognition changes and their environments change.”
Lange referenced the newly published second edition of Seating and Wheeled Mobility: A Clinical Resource Guide, which she and physical therapist Jean L. Minkel edited.
“I’m just so proud of all these wonderful authors,” Lange added. “The aging-with-a-disability chapter [chapter 27] was updated quite a bit and now has co-authors along with Susan. [Authors of that chapter are Susan Johnson Taylor, Bonita Sawatzky, and Lynda Bennett.] And those are definite factors because even if someone has a ‘non-progressive diagnosis,’ our skills change as we get older. This person may have been able to do something safely, but they may not be able to do anymore, or there’s an increased safety risk.
“So it’s figuring out: How do we do this differently? Maybe once upon a time, you could do that huge transfer from your chair right into the driver’s seat of your car, and then take this huge [wheelchair] and pull it up and put it over [to the side of the driver’s seat]. That’s a really hard thing to do. [Eventually], that way of getting in and out of your vehicle isn’t working anymore. We need to look at something different. Or maybe we look at how you’re getting in and out of bed, or transferring to a shower chair. We know, too — though this is getting better with a lot of technology out there — that someone who’s been self propelling for years has serious consequences to shoulders, elbows, wrists sometimes. There are definitely people who have to relook at this: Do they need a different manual chair that works better for them, with a better configuration? There are so many cool power-assist options now. Or do they need power [mobility]?”
“Ongoing assessments of mobility, positioning, skin and tissue health, independence, and safety are recommended to follow progressive conditions and the need for new wheelchair skills and CRT,” Wade said.
Ultimately, wheelchair skills will evolve through a rider’s lifetime — and therefore need to be regularly reviewed and reassessed. “Teaching wheelchair skills is a rewarding process that can enhance a user’s independence and quality of life,” Wade said. “The key to success with wheelchair skills is to prioritize safety and meet your client where they are.”
Editor’s note: This story originally appeared in Mobility Management’s March ebook digital edition. Read the rest of the digital edition online.
