If there is one mantra in complex seating & mobility, it’s this: Every client must be assessed as an individual, because no two clients are exactly the same. That’s a wise principle when approaching any new client who needs assistive technology support.
That said, even in this clinical niche there are some expectations that have been formed from years of experience. For instance we know how ALS progresses. And that infants with spinal muscular atrophy type 1 will not crawl or walk.
With spinal cord injuries (SCI), there is a general set of clinical expectations based on where the injuries occurred. But in reality, patients with SCI, even those with injuries in the same location, can have significantly different presentations.
And for clients with C5/C6 injuries — i.e., injuries at the fifth or sixth cervical vertebra — the differences from client to client can be even greater.
For these clients, wheelchairs custom fit to their required specifications can offer independent mobility indoors and outdoors. But is a power chair the answer? Or would an ultralightweight manual chair be a better fit?
Understanding C5 & C6 Injuries
A spinal cord injury at the C5 or C6 level impacts a number of functions and functional abilities.
“In general a client who presents with a C5 SCI is able to utilize several muscles that control the shoulder girdle, which allows active movement in all directions and is instrumental in achieving a pushing motion on the rear wheels of a manual wheelchair,” says Angie Kiger, M.Ed., CTRS, ATP, clinical education specialist for Sunrise Medical. “This client should also have the ability to perform some elbow flexion.”
For clients with C6 injuries, Kiger says, “The shoulder and bicep muscles have the potential to become stronger. In addition the client should also have the ability to pronate his/her wrist as well as extend it and complete a tenodesis pattern — passive thumb adduction on the index finger during active wrist extension — which can also lead to a better, stronger push on the rear wheels.”
Lois Brown, MPT, ATP/SMS, rehab clinical education manager for Invacare Corp., says, “If complete, C5 injuries typically result in lack of finger or wrist movement, lack of elbow extension and good elbow flexion. With C5 there is significant weakness in the scapular stabilizers, and with that comes pain and instability. Because the scapula affects overall range of motion and functional use of the upper extremities, this is a big factor in recommending manual propulsion.”
She says C6 injuries, if complete, “typically result in lack of finger movement, wrist flexion and elbow extension, but good control of elbow flexion and wrist extension. In a C6 injury, grasping items can be achieved via tenodesis with wrist extension leading to passive finger flexion. If either injury is incomplete, the presentation can vary significantly with active movement in varying muscles below the injury level. The patient could have significant active movement through the arms, trunk and even legs.”
So why is a power-or-manual-mobility conversation common for clients with these levels of injuries?
“The discussion comes up,” Brown says, “because these patients have good shoulder control and, with modifications to the wheelchair setup, the client can typically propel a chair for at least short distances without help.”
With C5 clients, “When the ability to control the shoulder girdle is combined with elbow flexion, it is likely that with proper adaptive equipment the client will be able to independently propel an ultralightweight manual wheelchair,” Kiger concurs. “Adaptive equipment may include projection handrims (vertical and oblique), vinyl-coated handrims, or handrims with low-tech solutions (i.e., rubber bands, tape or Coban self-adhering wrap) wrapped around them to assist with grip when completing a palm-to-wheel strike.”
Considering Environmental & Personal Factors
Determining and understanding a client’s physical abilities is only the beginning of completing the mobility equation, however.
“The primary environments the chair will be used in are also extremely important to consider,” Brown says. “If the user has steep hills to climb, rough terrain to pass over, significant distances to cover regularly, etc., they will more than likely require a power chair to be successful. However, if they will not be able to obtain transportation for their power chair or live in a home that cannot be adapted appropriately, a manual wheelchair may provide greater independence overall.”
Erin Michael, PT, DPT, ATP, physical therapist III, is the clinic equipment coordinator and seating & mobility specialist at the International Center for Spinal Cord Injury, Kennedy Krieger Institute, in Baltimore. She recalled an instance in which the environment played a role in the eventual mobility decision — but so did other unique circumstances.
“I recently had a case where a patient and his family live in a splitlevel home,” she says. “With a power wheelchair the patient would have been limited to one room of the home, whereas with a manual chair, he can be bumped up a couple steps by his brothers to access multiple rooms of the home.
“The patient’s desires should definitely be considered. It is very important to actively involve your patient in the evaluation process and have an open discussion/interview regarding their mobility goals. If they have a desire to drive, how would they like to do that? What kind of vehicle are they hoping to obtain? If they would like to travel, where would they like to go? How will they be getting there?”
Michael also notes it’s important to talk about the environments in which the wheelchair will be expected to function.
“What are their mobility requirements for work and/or school?” she asks. “If the school campus has many hills, or if they will have to travel great distances to get between rooms or buildings between classes, they may not be able to make it in time with a manual chair. Or if they make it there, they may be so exhausted that they cannot participate.”
Michael also suggests determining the many practical activities and errands that need to be carried out each day. “The tasks they will perform at work must be considered: Do they have to carry items, and can they push and do this at the same time? And so on. All daily tasks, such as grocery shopping, banking, getting hair done, going out to eat, should be investigated.”
During evaluations, Kiger also considers what clinically related changes could be anticipated: “Upcoming surgeries, medication changes, medical procedures, progression of the medical condition if applicable, etc.”
In that vein, clinicians and providers sometimes also have to consider recommending changes to seating & mobility equipment decisions as a client’s medical condition changes.
“Did the client have a change in cognitive function — i.e., onset of dementia, seizure activity, stroke, etc.?” Kiger asks. “Does the client have a degenerative condition? Is the client scheduled to have a surgery, procedure or change in medication that could change his/her level of function — a gain or loss in skills? Was there a change in function due to a repetitive stress injury?”
“There are many changes that occur over a lifetime that can result in a change in recommendation,” Michael says. “Some of these include changes in the patient’s functional level, either continued recovery or a functional decline; changes in shoulder, elbow or finger range of motion; development of upper-extremity pain; change in daily routine or activities; change in life plan and, therefore, mobility goals, etc.”
Manual Mobility: Some Possible Red Flags
Given their way, a lot of clients with SCI in the C5/C6 range would rather propel themselves in ultralightweight manual chairs than wield a power chair’s joystick.
“Many patients prefer to have a manual chair, if possible, because of the stigma associated with power — greater disability — and because of the convenience of transport in a manual chair,” Brown says. So why not recommend ultralight chairs for these clients?
“It becomes a conundrum for therapists recommending mobility equipment because we have a goal of preserving the shoulder complex and distal upper-extremity joints, protecting them from overuse injuries,” Brown explains. “The arms are not made to be the primary weight-bearing extremities of the body, but they assume this role after a SCI. An injury to the arms from overuse can cause significant loss of independence: The patient can no longer transfer on their own, perform activities of daily living and so many other daily tasks.”
ATPs therefore need to try to balance a client’s preferences with other concerns.
Says Michael, “A significant detail in this decision is propulsion pattern. If the patient must utilize significant compensations to create a push stroke, such as shoulder abduction, which maintains the shoulder in misalignment throughout each stroke, I will recommend power over manual. A poor propulsion pattern puts a patient at very high risk for overuse injury.”
And while the ability to safely self propel is a major factor in the decision-making process, Michael adds that being able to stop the chair safely is also critical.
“The patient must be able to propel at a reasonable and safe speed to get between destinations, across streets and over obstacles,” she points out. “In addition, the user must be able to demonstrate consistent ability to stop the chair; otherwise, they will be at risk for significant injury to themselves and/or others.”
Kiger offers a list of major, though not the exclusive, clinical factors that can determine whether a clinician will recommend power or manual mobility:
- A client’s consistent active range of motion and strength in his/her upper extremities;
- Motor coordination (praxis), as well as sensation;
- Cognitive status and skills: Important areas to look at include direction following, problem solving, decision making, and safety awareness;
- Respiratory and cardiac status: Medical conditions such as congestive heart failure, coronary artery disease, and chronic obstructive pulmonary disease can make manual propulsion a challenge and make powered mobility a better option;
- Vision: acuity and perception.
Michael also examines the client’s ability to perform effective pressure relief: “One should assess the patient’s ability to perform forward or lateral leans. If the patient cannot do these independently, a power chair can provide power seating functions that can ensure independence with pressure reliefs.”
And while ATPs are checking a client’s ability to perform independent weight shifts, Brown adds, “What is the weight and size of the patient? In other words, is manual propulsion a reasonable goal?”
She also suggests examining the client’s activity level prior to injury: “Is this a type of person who is going to be get out there and be able to ‘effectively push’ the chair and engage in meaningful functional activity in a manual wheelchair?”
One factor that should not automatically preclude a client from trying to self propel: Age.
Brown points out that the risks of many co-morbidities such as histories of shoulder and other upper-extremity injuries or pain are more likely to increase as clients age, as is the likelihood of other difficulties, such as cardio-respiratory illness. But older clients can still be individually assessed for their ability to self propel.
And on the other end of the age spectrum, being very young shouldn’t prevent a client from being assessed for self-propulsion either, Kiger says.
“As long as the client has the clinical needs and exhibits the required skills,” she explains, “age should not play a factor in the decision process. The age range these days spans from 18 months to over 100 years old! It is important to note that as with all other forms of early intervention, the earlier a client is introduced to independent mobility, whether it is with the assistance of a walker, manual wheelchair or power wheelchair, the better.”
Working to Overcome Power Mobility Resistance
Power chairs can be the better choice for many SCI patients with higher-level injuries, but they can also be an emotionally tough sell. Clients with injuries in the C5/C6 range may resist the notion of power mobility, perhaps insisting that propelling a manual chair will help them to stay in shape and keep unwanted pounds off .
How can clinicians and providers counter that argument?
“The most important point to discuss with clients, caregivers, and/ or clinicians is that a manual wheelchair is not a piece of exercise equipment,” Kiger says. “All mobility devices are pieces of equipment that are to be used to assist in maximizing independence with activities of daily living. If any of the aforementioned parties are concerned that the client will gain weight or lose function, advise them to look at the client’s overall health and wellness plan. Additional exercises, stretches, dietary changes, and/or leisure activities may be beneficial to the client.”
“Off ering the clients as many options as possible, while expressing the pros and cons of each, is really important to this process,” Brown says. “Using examples or scenarios that they mayfind themselves in can help them to better visualize the pros of power.”
As for another common complaint about power mobility — that power chairs make consumers look “more disabled” than they would if they were in ultralight chairs, Brown says, “I also try to give them a different ‘spin’ on the power chair than they come in with. Power chairs tend to have a negative stigma associated with them because of the ‘level of disability requiring one’ and because of their size. Many of my patients will express feeling overshadowed by the pure size of the chair. They want to be seen first, not their chair.
“So I try to discuss the many benefits: conservation of energy for other tasks — using the power chair as a vehicle to get to a destination — and maintaining independence across all aspects of life; potential loss of function with an injury to the arm; ability to traverse varying terrain and at higher speeds. I also try to discuss scenarios specific to that patient’s life and goals.”
“Addressing the concern that the client ‘doesn’t want to appear to the world to be more disabled’ can be a challenge,” Kiger acknowledges. “The ATP and clinician should state that while they may not be able to directly relate to what the client and/or family are feeling in this area, they do validate that perception is a real concern of not only clients, but also families. Next, focus on the quality of life improvements that can be achieved via powered mobility utilization. Focus the discussion on achieving independence in the best way to overcome this potential obstacle.”
What about using a hybrid of the two types of technology?
Brown says, “While power assist is a discussion within itself, it can be a consideration with this patient population if they are unable to accept the use of a power wheelchair. But know that manual mobility will not help them achieve the outcomes and functional activities they are hoping to accomplish.
“Power assist requires a very careful assessment, as while the wheels add power and distance covered, there is a safety issue of control of the wheels and wheelchair, which requires upper-extremity fine motor coordination and control.”
Talking with patients when they’re having trouble accepting power mobility and helping them to understand the consequences of their decision can be undeniably difficult and time consuming. But Brown points out that these discussions are crucial to achieving a good outcome.
“Ultimately, the decision is up to the patient, and it is important that they feel that way,” she says. “Pressuring them into something is not the answer. It could result in abandonment of the chair.”
In the End, an Individual Decision
It is imperative to know how C5/C6 injuries impact clients’ functions. But that’s not the only information critical to a successful outcome.
“With all of that said,” Kiger says, “it is worth pointing out that clients with the exact same diagnosis do not always present identically. Prior to jumping too far into the discussion of mobility options with a client, it is important to have an understanding of the diagnosis as well as a complete understanding of the specific client’s medical history, including whether or not the injury is complete or incomplete and how your specific client is functioning.”
Likewise, each client’s living environments, future plans and goals will be unique — further emphasizing how each assistive technology decision is an individual one.
Kiger says, “Not enough can be said about the importance of a thorough evaluation…. First and foremost, each client should be considered on an individual basis.”
Says Michael, “It is important to fully understand the patient’s and/or the caregiver’s primary goals for the mobility device, related to all aspects of their life. Perhaps neither style of chair will make them independent with all of their mobility goals, but which type will check off the most items on their list in the safest and most efficient fashion? This decision is made on a completely individual basis.”