Wheelchair 101

People are not “confined” to their wheelchairs -- they are in fact liberated by their wheels. A person with paralysis can get around as quickly in a wheelchair as anyone else can walking. A wheelchair offers people access to work and shopping or any other travel outside the home.

In some ways a wheelchair is like a bicycle: There are many designs and styles to choose from including imports, lightweights, racing models, etc.

The chair is also like a pair of shoes -- there are distinct styles for special purposes, such as tennis or rugged trail use. If the fit isn't just right the user can't get comfortable and therefore can't achieve maximum function.

Selecting the right chair, especially for a first-time wheelchair user, can be confusing. It's always a good idea to work with an occupational therapist (OT) who has experience with various kinds of wheelchairs.

Many people choose their first chair because it was the one the insurance company was willing to pay for. The second one, though, is often selected because of styling, performance or other features.

Manual chairs

People with upper body strength typically use a manual chair -- it is propelled, of course, by pushing the arms forward as the hands grab the wheel rims.

A little over a generation ago, the standard chair was a chrome-plated behemoth that weighed about 50 pounds. Today's standard chair comes in every color you can think of and is much less than half that weight.

The modern chair is designed for far superior performance -- they ride truer and are much easier to push than the clunkers of yesteryear. The lightweights, whether with a rigid frame or a folding frame, are also easier to lift in and out of cars.

Generally speaking, a rigid frame (one that does not fold up) transfers more of the rider's energy into the forward motion than does a folding unit. The primary advantage of a folding chair, however, is portability; some folding units can even fit in the overhead bin of an airplane.

In recent years, chair makers have added suspension systems as an option, which smooth the ride considerably. The trade-off in ride quality is with weight (shocks add a few pounds) and price (higher).

Aftermarket products (i.e. Frog Legs) are also available to add suspension to the front forks. These are very popular and have been approved for reimbursement by Medicare. Another key innovation is the use of super-light titanium in wheelchair frames. Light is better for the shoulders. Ti leads the pack in the U.S.

There are also lots of options for wheels and tires, including innovations for performance, off-road traction and high style. A company called Spinergy created a high performance line of wheelchair rims. They are light and stay true. The company recently brought out an innovative push rim. The soft rubber FlexRim bridges between the rim and the tire, allowing for an easier, low impact push that protects hands and arms from impact.

Propulsion alternatives: You don't have to push a rim on the wheel to make the chair go. There are a couple of lever-driven chairs on the market, both touting that shoulders don't get damaged the way they can with standard rim pushing.

  • The Pivot Dual Lever Drive replaces the quick-release rear wheels of any manual wheelchair; the Pivot comes with five levels of effort.
  • The Wijit Wheelchair lets the user push half as much as they usually do with a conventional wheelchair.

Power chairs

A person who can't push may require a wheelchair or scooter powered by an electric motor and batteries and controlled by a joystick.

Power chairs come in several basic styles. The traditional style looks like a beefed-up standard issue wheelchair, along with all the extra bulk of the batteries, motor and control systems. There are also platform-model power chairs with a more ordinary-looking seat or captain's chair fixed atop a power base. Scooters come in three- and four-wheel configurations and are most often used by people who don't require them full-time.

Twenty years or so ago, the power chair market was limited to just a few brands and models. Innovation has expanded the choices toward lighter, more powerful and much faster chairs. Most power chairs have rear-wheel drive, but mid-wheel and front-wheel drives have grabbed a share of the market. These are easier to turn and are quite nimble in tight spaces.

There are models that are rugged and off-road ready; there are models that fold for travel; there are power chairs that can be customized for the most complex needs of people with paralysis. The right choice for each user is based on much more than style.

Getting a power chair fitted and configured to one's needs requires expert help, from an OT or reputable durable medical supplier. How do you find the right supplier? Ask around, ask an OT, read the very active gear discussion boards online.

Need a new chair? You'll need to work with your funding sources, your OT and seating specialists, and your rehab supplier to get the best chair for your needs, and to defend your choice in the event of a reimbursement denial.

To be sure, reimbursement is a key issue for all durable medical equipment purchases, especially for high-ticket items such as power chairs (which can cost more than a fully loaded Honda). The power-mobility industry has been the target of federal investigations into Medicare fraud.

According to a 2011 government report, 80 percent of Medicare claims for power wheelchairs did not meet coverage requirements and should not have been paid by Medicare. So, in an attempt to curtail fraud, Medicare has changed some of its reimbursement rules. That, along with a choice-limiting system of competitive bidding, has been met with much resistance in the disability community.

Batteries

Battery life is a crucial issue for power chair users. Failure to manage this power source can lead to sticky or annoying situations, especially if you're far from home.

Power chair batteries must be of the 24-volt “deep-cycle” variety, discharged over long periods, as opposed to a battery in a car (12-volt) used for short bursts of power. Deep-cycle units come in several sizes: e.g., Group-22, Group-24 and Group-27. The larger the group number, the larger the battery and the more power it stores.

There are three types of batteries:
Lead-acid or “wet” batteries create electrical energy when lead and sulfuric acid interact. These battery cells need to be periodically filled with distilled water, maybe once a month. The main advantage of a wet-cell battery is the lower cost. The main disadvantage is that they may require special handling, especially when you fly.

Gel batteries don't have liquid to spill or top off. They are more expensive than wet battery versions, but they have a longer life cycle and are much preferred for airline travel.

Absorbent glass mat (AGM) batteries, like gel units, don't require maintenance and are fine for flying. They are very rugged, hold a charge better and last twice as long as standard lead-acid batteries. They are also the most expensive.

Wheelchair batteries are sometimes the same as those used in the boating industry. If you pay for your own batteries out-of-pocket, you might save money by purchasing marine deep-cycle batteries. Be sure and check with your chair manufacturer's specifications.

Power assist

The standard lightweight manual can be tricked-up with a small, powerful motor, affixed to the wheel units or attached to the base of the chair. When the assist is turned on, a forward push on the handrim gives the chair a strong boost.

The e.motion fits many types of chairs. The Xtender is available on some Quickie models in two versions, one that increases the force applied to the handrims by a factor of 1.5 and one that boosts you by a factor of 3.

These assist hubs add quite a bit of weight to the chair (from 38 to almost 50 pounds) and quite a bit of expense ($5,000 to $8,000), but the advantages are terrific, especially for lower-level quads and anyone with achy shoulders who won't have to struggle up steep hills.

A rider's range will increase dramatically using the assist, saving personal energy and wear and tear on the rotator cuffs. What's more, the chair doesn't look like a beefed-up power unit: It looks more or less “normal.”

SmartDrive is a newer power assist option for manual chairs. This is a portable drive wheel (11 pounds) that pretty easily hooks on to the base of the chair; a battery fits under the seat.

Another option, this one without batteries or motors, MagicWheels, two-gear wheelchair wheels that have a lower gear for hills when you need it, with a click of the hub, at about a third the cost of power assist units.

If users emphasize the potential increased health benefits of power assist devices (saving the shoulders), many insurance companies will cover them, including Medicare.

Kids' chairs

Children's bodies are growing and changing, which means their chairs must be adjusted or replaced more often than adult chairs. Since chairs are not cheap and insurance providers often place limitations on replacement, most manufacturers offer adjustable chairs to accommodate a growing child.

Wheelchair companies also offer chairs for kids that don't look as “medical.” The updated looks offer more streamlined designs, cooler upholstery, and different frame colors.

Colours offers the Little Dipper, or the Chumpe. Likewise, the Sunrise Quickie Zippie and the Invacare Orbit are made for younger wheelers who want to ride with a bit of style.

Seating and positioning

People living with paralysis are at high risk for pressure sores and therefore usually require special cushions and seating systems to give the skin some relief.

There are several basic kinds of cushion material, each with benefits for certain types of users: air, foam or liquid (e.g., gel), a variety that is more dynamic, with moving parts.

There is no single product that will do the job for all. The right cushion can provide comfort, correct positioning and prevent pressure sores, but it need not meet all those criteria for every user.

An ambulatory person who only uses a wheelchair to go shopping doesn't have the same needs as a high-level quad who spends eighteen hours per day in a power chair, so it's important to fully understand your requirements and select the appropriate cushion, weighing the pros and cons of the different styles.

Foam is the least expensive material for a cushion. It's also lightweight and doesn't leak or lose air. It does wear out, though, losing its compression over time.

Air flotation cushions, such as the popular ROHO model, provide support using a rubber bladder of evenly distributed air. These work well but can leak; they also require air adjustments when you change altitude.

Another type of air cushion, the Vicair Vector, employs many small, permanently sealed air cells. The cushion can be adjusted by unzipping the liner and removing or adding air cells. The BBD air cushion is a single-chamber models are still widely used for inexpensive pressure relief. Gel cushions, such as the Jay, are filled with slow-flowing gel. They are popular and effective for skin protection, but are also somewhat heavy.

Aquila is an example of a dynamic cushion; it features an oscillating pump that alternates pressure. The theory is that seating can continue for longer periods of time if pressure is alternated with no pressure. This adds weight to the chair and, because the pump runs on batteries, is not as carefree as a static cushion.

Another dynamic pressure-changing cushion is the Ease. Some users might benefit from a custom cushion, made to fit their body. The Aspen line uses a thin contoured plastic shell generated from client mold.

For a list of available cushions and seating systems see AbleData or USA TechGuide, which offers reviews of many wheelchair-related products. It's best to work with a seating and positioning expert to pick the right product.

Tilt or recline

Some people use special wheelchairs to distribute pressure and thus reduce the risk of skin sores. These chairs also increase comfort and sitting tolerance.

One type of chair, called “tilt in space,” changes a person's orientation while maintaining fixed hip, knee and ankle angles. In effect, the whole seat tilts. The other chair option is a recline system, which basically changes the seat-to-back angle, flattening out the back of the chair and, in some cases, raising the legs to form a flat surface.

A tilt system redistributes pressure from the buttocks and posterior thighs to the posterior trunk and head. The system maintains posture and prevents sheering (the friction on tissues from dragging across a surface). A drawback: If a user sits at a workstation, for example, the tilt requires that he or she move back from the table to avoid hitting it with the knees or footrests.

Recline systems open the seat-to-back angle and, in combination with elevating leg rests, open the knee angle. There are some advantages to a recline system for eating, making transfers or assisting with bowel or bladder programs, as all are easier when lying down.

Generally speaking, the recline system offers more pressure relief than tilt, but with a higher risk of sheer. Elevating the legs may be beneficial to people with edema. Both tilt and recline must be fitted and prescribed by seating and positioning experts.

Standing

Standing chairs act as normal manual chairs but also help the rider rise to a standing position. There are many advantages to being tall at home, in school and in the workplace.

Some manual chairs come with a power assist to activate the rising mechanism. Some power chairs also enable the rider to rise to a standing position, with the advantage of eye-to-eye contact with others. See Permobil or Redman.

The drawback: They are not cheap and are heavy for an everyday chair. Standing has physical benefits, too. It helps to prevent pressure sores, improves circulation and range of motion and, for some, reduces spasms and contractions.

A few years ago the Hines VA reported that people who stand for 30 minutes or more per day “had significantly improved quality of life, fewer bed sores, fewer bladder infections, improved bowel regularity, and improved ability to straighten their legs.”

Standing frames are also available. EasyStand offers several models, including a pediatric unit. Some, such as the Stand Aid, are motorized. Other standing frames are more rudimentary -- basically a static frame that supports a paralyzed person in the standing position.

Resources

There are other specialty chairs available, including ultra lightweight three-wheelers for road racing; chairs with extra camber for tennis and basketball (they don't tip over); heavy duty four-wheelers for off-road use; chairs with big puffy tires for the beach, and even chairs with tractor treads for those who cannot resist negotiating the roughest of terrain.

If you are looking for more information on wheelchairs or have a specific question, our information specialists are available business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9:00 am to 5:00 pm ET.

Additionally, the Reeve Foundation maintains fact sheets on wheelchairs with additional resources from trusted Reeve Foundation sources. Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis.

We also encourage you to reach out to other support groups and organizations, including:

  • USA TechGuide is a guide to wheelchairs and ­assistive technology, including numerous reviews of mobility gear. Sponsored by United Spinal Association.
  • WheelchairJunkie is a resourceful and opinionated website operated by self-described “power chair gonzo” Mark E. Smith.

This project was supported, in part by grant number 90PR3002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.