A new position paper from RESNA focuses on the complexity of ultralightweight manual wheelchair prescription — not just the choosing of the chair, but also customized fitting and dialing in of a host of measurements and components that need to work together.
The paper, called “The Application of Ultralight Manual Chairs,” has been in the works for about two years, says co-author Lauren Rosen, PT, MPT, MSMS, ATP/SMS.
“As an industry, we’ve known for awhile now that provision of ultralight wheelchairs has been getting more and more difficult,” she explains. “Like all the other areas of wheelchair provision, there’s not a ton of research that has been done. Like all the other (RESNA) position papers that are out, what this position paper aimed to do was to combine the available research that we have — the most up-to-date, everything that’s out there — along with the best clinical practices that are going on in the clinics as well.”
In addition to Rosen, the paper’s authors are Carmen DiGiovine, Ph.D., RET, ATP; Theresa Berner, OTR/L, ATP; Kendra Betz, MPT, ATP; Tina Roesler, PT, MS, ABDA; and Mark Schmeler, Ph.D., OTR/L, ATP.
The six authors intentionally hail from different practice areas, Rosen says — “OT, PT, rehab technology. Some people are more in the research and educational areas; one works for a manufacturer. We tried to capture all of the participants in the process of doing a wheelchair for somebody so we could get all of the best clinical practice opinions.”
Finding the Right Fit
The paper discusses multiple factors that can ultimately impact an ultralight chair user’s functional success, including seat slope, seat-to-back angle, leg-to-seat-surface angle, rear-wheel camber, position of the rear axle, wheel type and size, and backrest height.
How did the authors decide which factors to discuss in the paper?
“We discussed all of the issues that matter with wheelchair provision and how each of those things would aff ect propulsion and function,” Rosen says. “If you were to look at an order form for an ultralight manual wheelchair, you would see choices for all of these things: your front seat-to-floor height, your rear seat-to-floor height, your legrest length, your seat depth, your seat width. Those are all adjustments that we feel are critical to getting things right.”
And are all of those measurements and specifications equally important to a good ultralight fit?
“In the grand scheme of things, they work out to be equally important because to get a well-fitted chair, all of that has to be correct,” Rosen says. “Some things will affect propulsion more than others. If your seat depth is too short and you’ve got too much weight bearing, it could increase the pressure sore risk, where other measurements wouldn’t have an effect on pressure sores. Every measurement affects different things, but what we’re trying to get across is that all of them matter, and that in order to do these wheelchairs right, the team, including the patient, has to understand those measurements and why they matter and how to do them properly for that individual.”
An Ideal for All Clients
Asked if these practices are true for all clients, regardless of diagnosis or age, Rosen says, “Yes, and that’s a point that sometimes gets overlooked with certain populations.
“Sometimes when you have an elderly individual who you know is not going to be out hopping curbs or be as active as a 19-year-old with spinal cord injury, people don’t think about making sure the axle is in the exact right position for that individual. But in some cases while they’re not as likely to be out hopping curbs, they’re more likely to have shoulder problems because of their age and arthritis.”
The goal, Rosen says, is “looking at each patient as an individual, not as a diagnosis.”
She adds, “There’s no perfect chair that you know, just by picking it, is going to work for everybody. It’s how you set that chair up that matters.”
The new position paper goes into considerable detail regarding the various measurements, adjustments and component choices possible on an ultralight chair: For instance:“With regard to the horizontal position of the rear wheel axle, if it is too far rearward the chair will be more stable, but an individual will have to place his/her upper extremities in a less efficient and potentially injurious position to access the handrim during propulsion.”
Part of the reason for making those distinctions in the paper, Rosen says, is to help stakeholders understand how important adjustability is — and how ultralightweight chairs answer that call.
“The biggest thing is the axle adjustability,” Rosen says. “It’s one of the biggest differences between (ultralight) K0005s and any of the classes below them. K0005s have more axle adjustability in all planes, vertical and horizontal, than a K0004 (lightweight chair) does. There’s no way you can adjust a K0004 to the specific positioning that you can on a K0005. That’s why in the paper, there’s all the discussion about vertical height and horizontal, center of gravity, getting them into that position.
“Going between a K0004 and a K0005, there is a weight difference as well. We’re not focusing on weight because it’s not the largest issue. It’s the adjustability of the chair and the ability to get the legrests where you need them. There are no rigid K0004 chairs, so if you have somebody who has hamstring contractures, who needs their legs further behind them, you can’t do that with a folding-frame chair. Rigid-frame chairs are designed to have the footplate narrow so you can get somebody back. It’s all the adjustments that are available.”
While lightweight K0004 chairs do have some axle adjustability — a fact that funding sources sometimes use to justify their preference for a K0004 instead of a K0005 — Rosen says it’s “not the amount that you need for someone who is a full-time wheelchair propeller.”
“Funding sources,” she adds, “are looking for the least-expensive product that will meet a patient’s needs. That’s their job. So it’s our job to help them to understand why this adjustability is necessary, and why it’s necessary for this particular individual.”
Setting Up for Success
Rosen says the paper’s authors expect it to be most widely read among therapists, equipment suppliers and funding sources, as well as some researchers and consumers.
As for how the authors would define an ultralightweight success story, Rosen says that, too, varies from client to client.
“If they’re already in a well-fitted chair, a success story is if we get them a new chair and they continue to have the same quality of life they had before,” she notes. “But in a lot of instances, you’re starting from the wrong style of chair — they’re going from a K0004 to a K0005 or a K0009. The success story then is that you do see an improvement in quality of life, that you do see that they’re able to be more active.”
Some success stories are immediately obvious, while others take more time to reveal themselves.
“Sometimes, right at the initial delivery, they’re propelling faster,” Rosen says. “Their arms are at a more relaxed position, their shoulders are down. When you ask the patient, ‘How does this compare to your old chair?’, they say, ‘Oh, this is so much easier. I had no idea this could be so much easier.’”
Other times, success is achieved more gradually.
“Especially with new chair users, getting that actual sweet spot can take more than one appointment,” Rosen says. “They’ve got to have the chair, take it home, use it for a few weeks. And then you realize, ‘That axle position is not exactly correct. Let’s move it half an inch further forward or backward.’ That’s part of the adjustability of these chairs — having the ability to do that so that for your newer users who don’t have chairs that are completely dialed into them from the very beginning, you’ve got the ability to tweak it and get it exactly where it needs to be.”
Another Tool at Hand
Given the complexity of properly fitting an ultralight chair to a particular user — and the justification needed to get the funding source to sign on — Rosen and her colleagues hope the new position paper can help streamline the process.
“By combining research and best clinical practice, it gives the readers one easy place to go to get all of the information that they need,” she says. “It makes it easier to reference to a funding source, and they’re more likely to read this than to go find 50 articles that all say different things.”
For the record, Rosen adds of the authors, “We are a neutral professional body of individuals. We’re not beholden to any funding sources or manufacturers. Everybody who was part of this project was volunteering to be part of this project. Nobody was paid.”
The paper is available as a free download (see Propulsion Resources).
“One of RESNA’s missions is to promote the health and well-being of people with disabilities through access to technology solutions,” Rosen says. “At the end of the day, that’s what we’re looking for: To improve people’s quality of life.”
And that goal should extend to every seating & mobility client, whether a 20-year-old athlete with a new spinal cord injury or a senior who’s had a mild stroke.
“In my mind,” Rosen says, “there’s nobody who doesn’t warrant a thorough evaluation by trained personnel for any kind of rehab equipment.”