Wheelchairs: one size does not fit all.

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 with 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.

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

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.

[ILLUSTRATION OMITTED]

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.

[ILLUSTRATION OMITTED]

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 multi-disciplinary 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.

Interview with Deborah Gavin-Dreschnack, PhD

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 [phone]. To send your comments to the author and editors, please e-mail [e-mail]. To order reprints in quantities of 100 or more, call [phone].