Focus On…Mobility & Rehabilitation

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?
Dr. Gavin-Dreschnack:
Gerichairs are used frequently for residents who cannot maintain upright posture. These chairs often are too wide for residents and generally do not offer lateral stability. Most gerichairs are used in the semireclined position, which can pose a serious threat to people with swallowing difficulty. Extended use of the reclining position also directs the user’s gaze upward and can promote sensory deprivation and social isolation. If the footrest section of the gerichair does not have independent movement from the frame, the user may be subjected to discomfort, strain of the hamstring muscles, and risk of contractures. A better solution is using a “tilt-in-space” chair that offers both tilt and/or recline and allows independent positioning of the footrest and legrests. These frames are usually very adaptable and, when appropriately fitted, can accommodate a wide range of positioning challenges.

What are some wheelchair modifications that might be considered to minimize the development of pressure ulcers and other physical problems?
Dr. Gavin-Dreschnack:
Each resident should be evaluated individually. Generally speaking, good pressure-relieving cushions can help to minimize the effects of extended sitting. Cushions may be gel, foam, air, polymer, or a combination of these and other new materials. Contoured, padded backs also can provide comfort and protection, particularly for residents who have bony spines and scapulae, or deformities such as kyphosis and scoliosis. Padded legrest panels can be used to keep feet and legs from falling between foot/legrests and into the casters, thus preventing injury. Arm troughs and padded trays may be useful in supporting a flaccid upper extremity and reduce the risk of subluxation at the shoulder. By providing lower frames that allow the user to reach the floor, many sliding problems can be resolved, and resultant shear can be reduced or eliminated.

What are some of the more healthful and supportive seating alternatives available for the nursing home population, and how might a facility set up a practical seating evaluation program?
Dr. Gavin-Dreschnack:
Wheelchair seating clinics should be an integral part of all nursing home protocol, and can be set up easily by rehabilitation staff with training and the support of administration. In establishing seating clinics, a multidisciplinary approach should be utilized. Ideally, the seating “team” would include the following:

  • rehabilitation staff (occupational/physical therapist)
  • speech therapist
  • nursing representative
  • family member
  • funding person (e.g., social worker, case manager, etc.)
  • experienced and reliable rehabilitation/wheelchair vendor (who often provides trial equipment)

To facilitate appropriate referrals to a formal seating clinic, I have developed a screening tool for use in nursing homes called the Resident Ergonomic Assessment Profile for Seating [REAPS]. It is simple, quick, and effective, and it can be used by any caregiver, with or without any previous wheelchair-seating experience.

Are there any risk-management issues that might arise from a facility’s improper use of wheelchairs?
Dr. Gavin-Dreschnack:
I was an investigator on the governor’s 2001 Task Force on the Availability and Affordability of Long-Term Care in Florida. I looked into all litigation cases involving nursing homes in Hillsborough County from 1990 to 2000. Many of the cases cited “inadequate care and inadequate training of staff” as the basis for their lawsuits. Furthermore, more than 60% of the cases I reviewed were either predicated on or inclusive of pressure ulcer formation in nursing home residents. Several cases specifically mentioned “lack of supportive surfaces” for residents who ultimately developed pressure ulcers. Wheelchair seating clinics help protect nursing homes from this type of liability by addressing (and documenting!) the needs of the residents. Another important factor, often overlooked, is the risk of injury to staff during repositioning of poorly positioned residents. This risk can be mitigated through use of an effective seating clinic. Cost savings are often realized by facilities that empower their residents to propel and eat independently. Proper wheelchair seating can enhance the safety and quality of life for residents and staff, as well as provide cost-effective marketing strategies for nursing home owners and administrators.

Deborah Gavin-Dreschnack, PhD, is a health science researcher at James A. Haley Veterans Hospital, Patient Safety Research Center of Inquiry VISN 8, Tampa, Florida. For more information, contact Dr. Gavin-Dreschnack at (813) 558-3935. To send your comments to the author and editors, e-mail To order reprints in quantities of 100 or more, call (866) 377-6454.
Invacare’s Deluxe 3-Position Recliner Series provides an alternative to prolonged bed rest by addressing the positioning and pressure-reduction needs of residents. Available in a wide range of models and styles, Invacare recliners offer a variety of functions and positioning capabilities.

Sitting in a reclined position with the head and neck supported provides kyphotic residents with a social link to their surroundings. Using a recliner may also help residents who have breathing problems, arthritis, or lower extremity swelling, or those recovering from surgery.

Victoria Cote, Invacare Continuing Care Group, 800-668-2337 x354,
Infrared Therapy
Anodyne« Therapy is monochromatic infrared photo energy used for increasing circulation and reducing pain. The Anodyne Neuropathy Care Center« Program helps to improve outcomes in patients who suffer from the complications associated with peripheral neuropathy. The ability to heal chronic wounds, reduce neuropathic pain, improve proprioception and balance, and decrease the risk of falling help to improve quality indicators.

Amy Spirides, Anodyne Therapy, 813-342-4432 x127,
Dual-Height Wheelchair
A dual-height wheelchair, the Elite Invacare Tracer« EX2 from Direct Supply has multiple seat width, depth, and height options, along with front rigging and armrest options. The double-embossed, 33-oz vinyl upholstery is flame retardant, bacteria resistant, easy to clean, and durable.

Anita Braun, Direct Supply, 414-358-7391,
Improved Stander
Altimate Medical’s EasyStand Evolv is the newest addition to the EasyStand Series. The EasyStand Evolv’s lifting design mimics the body’s natural pivot points, minimizing shear. Its redesigned modular base allows various options such as the sit-to-stand desk, self-propelled mobility, or the “Active Standing” Glider to be added at any time.

Transfers into the EasyStand Evolv are easier because of its wider seat and open base, which allow the user’s wheelchair to be positioned closer to the stander.

The open base also accommodates lifts.

Bryanne Freitag, Altimate Medical, Inc., 507-697-6393,
Rising Bed
NOA Medical’s “V” Riser bed moves straight up or straight down-from 7″ to 26″. It moves in any position and rolls at any height. Locking casters are always on the floor so the bed can be moved in any direction in case of emergency. Its built-in baseboard bumper and integrated battery backup (using 9V batteries) help to reduce costs and simplify maintenance.

Doug Proffitt, NOA Medical Industries, Inc., 636-239-7600,
Mobile Resident Chair
Carefoam has introduced the Model 510 Tilt Rollabout, a tilt-in-space chair. Infinitely adjustable, the chair allows the resident to be positioned from full upright to comfortable recline. Its large wheels make it suitable for both indoor and outdoor use. The Tilt Rollabout is appropriate for residents needing frequent position changes.

Nora Lee, Carefoam, 877-236-2687,
Heel Device
The Achil-Ease« from Primus Medical is used to prevent or treat heel ulcers by elevating the heels off the mattress, as recommended by NPUAP and AHRQ guidelines. It features a removable wedge to increase or decrease elevation and a strapping system that can be adapted to a resident’s height. Because it straps to any mattress, the Achil-Ease does not have to be removed when changing linens. It is designed for resident-to-resident use.

Mark Shaw, Primus Medical LLC, 330-965-9681,
The Arjo Walker provides a safe environment for both resident and caregiver. The manual or battery-powered Arjo Walker enables the caregiver to elevate a resident from a chair, bed, or wheelchair for ambulation training. Suspension straps provide maximum safety.

Amy Mccaw, Arjo, Inc., 630-307-2756,
Adjustable Tables
Space Tables, Inc., offers adjustable fiberglass tables that accommodate wheelchairs and ensure proper positioning for all long-term care residents. Available in three sizes and a variety of colors, the U-shaped table is engineered to maximize outcomes in restorative feeding programs.

Bobbi Davis, Space Tables, 800-328-2580,
Heel Support for Recliners
Intensive Therapeutics, Inc., has introduced a new version of the popular HeelZupÖ Heel Elevating Cushion, specifically designed for use on a reclining chair. It exceeds AHRQ and NPUAP guidelines; elevates heels a minimum of 1″ off the leg rest while supporting the lower leg; avoids hyperextension of the knee; has raised side bolsters that stabilize legs; adapts quickly to virtually any recliner without using straps or Velcro«; has a friction and shear reducing nylon cover; is made from hypoallergenic and latex-free foam; and increases compliance and decreases incidence.

Matt DuDonis, Intensive Therapeutics, Inc., 410-290-0734,
Seat Slide
Sit-RiteÖ is a one-way directional slide available from Mobility Transfer Systems. Place Sit-Rite on a wheelchair with the rotation toward the back of the chair. The resident is able to slide or be assisted back into the seat for better positioning. When residents are first placed in a wheelchair, they sit too far forward. When repositioning is needed, Sit-Rite allows the resident to move back in the chair with minimal effort. The slick inner surface creates minimal friction, making repositioning easier for residents and staff, while preventing injuries. By preventing the resident from sliding forward, seating posture is improved.

Thomas Leoutsakos, Mobility Transfer Systems, Inc., 800-854-4687,
Positioning Cushions
Crest Healthcare Supply’s affordable AlevioÖ cushions feature Visco Memory Foam that conforms to the user for added support and comfort. Alevio cushions use Recovery 5Ö high polyurethane covers that are incontinent-proof, antibacterial, latex-free, antifungal, flame retardant, and machine washable.

Four chair configurations are available: Zero Elevation, Wedge, Gel Pac, and 4-Chamber Gel Pac. The 4-Chamber Gel Pac keeps the gel in place under the ischials. It prevents gel migration while reducing heat and pressure. The double layer foam construction includes a top layer of Visco Memory Foam that molds to bony prominences and a bottom layer that provides additional support.

An Alevio Back Cushion for use in a sling-seat wheelchair is also available.

Customer Service, Crest Healthcare Supply, 800-328-8908,
Therapeutic Recreation
The WhisperGlide swing invites social interaction and appeals to all ages and abilities. Indoors or outdoors, a glider swing provides fun and relaxation. The WhisperGlide Swing offers a fun and safe activity for light exercise and social recreation for residents and visitors.

Marillyn Knuteson, WhisperGlide Swing Co., 651-439-5649,

Topics: Articles , Rehabilitation