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Focus On...Mobility & Rehabilitation

April 1, 2005
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Wheelchairs: One Size Does Not Fit All An interview with Deborah Gavin-Dreschnack, PhD
focuson Mobility & Rehabilitation

Wheelchairs: One size does not fit all

Interview with Deborah Gavin-Dreschnack, PhD Just like in the story of Goldilocks and the Three Bears, a "just-right" fit is imperative for people confined to wheelchairs. However, some people are more interested in choosing a chair to suit their sense of style or one that is within their price range; facilities are also guilty of overlooking the importance of the wheelchair. A chair that's too big or too small (or poorly constructed) can have harmful consequences. Nursing Homes/Long Term Care Management recently spoke to health science researcher Deborah Gavin-Dreschnack, PhD, about matching the individual to the wheelchair to ensure optimum safety, comfort, and protection.

Would you discuss the assertion that wheelchairs designed for short-range perambulation-"standard" wheelchairs-are being used as chronic resting places by the elderly? Also, that wheelchairs in most common use are unlikely to help most elderly women?
Dr. Gavin-Dreschnack:
While some community nursing homes are beginning to purchase a mix of wheelchairs (e.g., narrow, extra-wide, hemi [a chair that is or has the adaptability to be lower to the floor, enabling users to reach the floor for foot propelling], recliner, etc.), the majority still appear to buy "fleets" of wheelchairs, most of which are standard width with sling seats and backs. The problem is that these chairs, regardless of width, do not provide proper pelvic stability, but rather provide a "hammocking" effect that does not distribute weight effectively and causes the hips, legs, and knees to roll inward. Elderly women, particularly those who are short in stature and might have kyphotic spines, often cannot reach the wheels for independent propulsion. Another factor is the weight of the standard wheelchair, which can be 40 to 50 pounds, rendering it difficult, if not impossible, to self-propel. The height of the wheelchair seat from the floor also is an important consideration for nursing home residents who need to use their feet to propel. This is common after strokes that have affected one side of the body. What are some common disorders that can be caused or aggravated by poor wheelchair positioning?
Dr. Gavin-Dreschnack:
Inadequate or inappropriate wheelchair positioning can contribute to pressure ulcers, skin tears, bruising, skeletal deformities, dysphagia, impaired respiration and digestion, contractures, discomfort, agitation, inability to self-propel, visual impairment, incontinence, social isolation, unsafe transfers, falls, and injuries to both residents and caregiving staff.

Would you discuss how someone might be perceived as dysfunctional because of poor wheelchair positioning or kyphosis?
Dr. Gavin-Dreschnack:
Elderly wheelchair users who are not properly positioned often can be perceived as more dysfunctional than they are. For example, a person who cannot maintain upright trunk alignment may lean heavily to one side without adequate pelvic and/or lateral support. This can contribute to poor head and neck posture, inability to communicate and swallow, exhaustion, discomfort, and even drooling.

Let's consider Mrs. X, an elderly woman, five-feet tall, with severe kyphosis, who has been admitted to a nursing facility after having a stroke. She is initially placed in a standard, 18"-wide wheelchair with a sling seat and back, fixed-height armrests, swing-away footrests, and a 21" seat-to-floor height. As a result of the stroke, Mrs. X is limited to use of her left side only. She cannot reach the wheelchair wheel, since the armrest is as high as her shoulder, and she is too short to reach the floor with her feet. This situation renders Mrs. X totally dependent on staff for mobility, as she must be pushed in her wheelchair. Furthermore, her kyphosis causes her head to remain flexed forward, and swallowing is difficult. Her eyes are directed toward the floor, so it appears that she is unable or unwilling to interact meaningfully with others. Mrs. X appears to have many functional limitations, and she appears to require a great deal of assistance overall.

After a seating evaluation is conducted, Mrs. X is provided with a narrow, hemi (17" seat-to-floor height) frame wheelchair, a pressure-relieving cushion with a stable base, adjustable height armrests, and a contoured, padded backrest that is angled backward and recessed to accommodate her kyphotic spine. Now Mrs. X has armrests that accommodate her shortened arm height, thus enabling her to easily reach the wheel with her left hand. The lower height of the chair allows her to simultaneously use her left foot for propulsion. The new backrest facilitates upright posture, and Mrs. X can now assume a level gaze and keep her head and neck upright without strain. Her swallowing is immediately improved, and she is more comfortable. The improved seating allows Mrs. X to become independent in her wheelchair mobility and promotes social interaction. The way that Mrs. X is perceived by others is dramatically different. While this is just an example, it is not an uncommon scenario in many nursing homes today. What are some common problems caused by gerichairs, and how might they be remedied?