Wheelchairs provide mobility that can enhance function and community integration. Function in a wheelchair is influenced by wheelchair design.
To explore the impact of wheelchair design on user function and the variables that guided wheelchair prescription in the study setting.
A mixed-method, descriptive design using convenience sampling was implemented. Quantitative data were collected from 30 wheelchair users using the functioning every day with a Wheelchair Scale and a Wheelchair Specification Checklist. Qualitative data were collected from ten therapists who prescribed wheelchairs to these users, through interviews. The Kruskal-Wallis test was used to identify relationships, and content analysis was undertaken to identify emerging themes in qualitative data.
Wheelchairs with urban designs were issued to 25 (83%) participants. Wheelchair size, fit, support and functional features created challenges concerning transport, operating the wheelchair, performing personal tasks, and indoor and outdoor mobility. Users using wheelchairs designed for use in semi-rural environments achieved significantly better scores regarding the appropriateness of the prescribed wheelchair than those using wheelchairs designed for urban use (
Issuing urban type wheelchairs to users living in rural settings might have a negative effect on users’ functional outcomes. Comprehensive assessments, further training and research, on long term cost and quality of life implications, regarding provision of a suitable wheelchair versus a cheaper less suitable option is recommended.
A wheelchair is defined by the WHO (2008:11) as ‘a device providing wheeled mobility and seating support for a person with difficulty in walking or moving about’. Thus, the purpose of a wheelchair is to improve personal mobility. With enhanced mobility comes the opportunity for greater function, access to services, community integration and employment (WHO 2008). However, function and community access is influenced by variables like the user's functional abilities, the environment and wheelchair design (Scherer
Part of the focus of this article is on the impact of wheelchair design on user function. Wheelchair design features, such as the overall length, weight, frame type and width, seat configuration, wheel and castor type, arm and footrests, axle position and propulsion mechanism, influence function (Vegter
Features of the different categories of wheelchair available on national tender.
Variables | Cruiser® | Pacer® | Econorigid® | Roughrider® | All-Terrain Wheelchair (ATW®) and World Made 3 (WM3®) |
---|---|---|---|---|---|
Frame type | Four-wheel folding frame | Four-wheel folding frame | Four-wheel rigid frame with fold-down backrest | Four-wheel folding frame | Three wheel rigid frame with fold-down backrest |
Overall length (Using basic folding frame as standard reference) | Standard | Standard | Short | Short | ATW |
Recommended use | Temporary use, and attendant propelled indoor and level outdoor terrain | Indoor and level outdoor terrain | Indoor and level outdoor terrain | Indoor, level and uneven outdoor terrain | Indoor, level and uneven outdoor terrain |
Indoor function (Using basic folding frame as standard reference) | Standard turn circle |
Standard turn circle |
Small turn circle. Compact and manoeuvrable in tight spaces | Smaller turning circle than Cruiser |
Larger turning circle. May limit indoor manoeuvrability, but narrow low boom fits under furniture and in tight spaces |
Stability for outdoor use | Fixed high centre of mass and loading of front castors results in instability on uneven terrain. | Adjustable centre of mass |
Low, adjustable centre of mass that is distributed over rear wheels |
Low, adjustable centre of mass that is distributed over rear wheels |
As for Roughrider |
Propulsion ergonomics | No adjustability to enhance ergonomics | Can adjust seat vertically and horizontally | Can adjust seat vertically and horizontally | Can adjust rear wheel position horizontally | |
Postural support | Though tension adjustable backrest | Through tension adjustable backrest, and adjusting rear axle settings | Through tension adjustable backrest, adjustable back height, front castor and rear axle settings | Through tension adjustable backrest and adjustable back height and rear axle settings | Though adjustable back height and angle |
Transportability | Folds flat Footrests and armrests removable | Folds flat Footrests, armrests and rear wheels removable | Fold-down back rest, removable wheels, does not fold flat | Folds flat Similar to Cruiser with footplates and armrests removed | Fold-down back rest, removable wheels, does not fold flat Long boom requires more space |
Cost | Cost on tender approximately R1000.00 (±$100) more than Cruiser |
Design features must be matched to the user`s functional ability and posture support needs, and also to the environmental and durability requirements. Achieving an ideal match between user, wheelchair design and environment might be as difficult as it is important (Di Marco, Russel & Masters
Information from the wheelchair database of the Western region of the Eastern Cape Province (WREC) indicated that wheelchairs most suitable for indoor use and in flat outdoor environments (as are mostly found in urban areas) were mainly issued in this predominantly rural area. The reasons for this practice and its impact on user function are unknown. Thus, the objectives of the current study were to determine:
What the impact of wheelchair design was on user function and
What variables guided wheelchair prescription in this setting?
A descriptive, mixed-method design was used (Kroll, Neri & Miller
This study was performed in the WREC of South Africa. This region is similar to the rest of the Eastern Cape Province. Geographically it is a mountainous, hilly grassland environment, criss-crossed by rivers with muddy or sandy areas, depending on the season. The road infrastructure is poorly maintained and public transport is limited. Informal settlements are found throughout the region, with the majority of settlements in rural or semi-rural areas. Many people live in small ‘rondavel-type’ structures. Sanitary facilities and water is often shared and provided at strategic points in these settlements.
The 231 adults who lived in the WREC, and received a wheelchair from the Eastern Cape Department of Health (ECDoH) between 01 June 2010 and 30 June 2012, formed the study population. From this database 15 wheelchair users from rural areas and 15 from semi-rural areas were conveniently selected and invited to participate in the study. Users had to be 18 years or older for inclusion in the study, and needed to have had a government subsidised wheelchair for at least 3 months. Those with hired, loaned or privately financed wheelchairs were excluded.
The Functioning Everyday with a Wheelchair (FEW) scale (Mills, Holm & Schmeler
Functioning Everyday with a Wheelchair (FEW/FMA questionnaire)
Functioning Everyday with a Wheelchair-Capacity (FEW-C)
Functioning Everyday with a Wheelchair-Performance (FEW-P).
The findings presented in this article focus on results from the FEW/FMA, which focuses on functional abilities and is completed by wheelchair users. It consists of 10 self-report items which are scored using a 6-point scale from 6 = completely agree to 1 = completely disagree.
The WSC consisted of two sections: Section A collates demographic data such as:
diagnosis
the period the user has been using the current wheelchair
the occurrence of secondary complications like pressure ulcers.
Section B is a five category checklist to establish whether or not the prescribed wheelchair was appropriate. The categories are:
size
environment
postural support
function
biomechanics.
The WSC was developed from the Provincial Government of the Western Cape's standards for wheelchair prescription (PGWC DoH
Participant's details were obtained from the WREC wheelchair database. Participants were contacted telephonically until 15 living in rural areas and 15 living in semi-rural areas consented to participate in the study. An appointment for data collection, at a venue of their choice, was made. On meeting the participants the study was explained to them, their questions were answered and written informed consent was obtained. Participants were asked to complete section A of the WSC and the FEW/FMA questionnaire. Thereafter section B of the WSC was administered. Questions were translated into isiXhosa by a translator where necessary.
Quantitative data were analysed in consultation with a statistician from the Centre for Statistical Consultation (CSC) at Stellenbosch University (SU). Relationships between variables were tested with the Kruskal-Wallis test. A p-value of less than 0.05 was deemed statistically significant.
The 14 therapists who issued wheelchairs to the users who participated in phase 1 of the study formed the study population for the second phase of the study. Two could not be identified as there was no signature on the requisition form. A further two were unreachable (one had emigrated and another did not return calls despite several attempts). The remaining ten therapists were contacted telephonically and all consented to participation.
A self-compiled questionnaire, with open and close ended questions, was used to collect data from therapists. The questions focused on the therapists’ knowledge of wheelchairs available on tender and their perceptions of wheelchair prescription practice in the study setting. Of the ten therapists, nine had completed a basic wheelchair seating course and four had completed both a basic and an intermediate wheelchair seating course. These courses are based on the WHO guidelines for wheelchair provision in less resourced settings (WHO
Data were collected from the therapists through semi-structured interviews in English or Afrikaans, depending on the preference of the individual therapist. Interviews with therapists were electronically recorded and transcribed by an external scribe.
Content analysis was used to identify emerging themes from the transcribed data. The different themes were highlighted in different colours, e.g. all text in the transcripts related to funding challenges was highlighted in green and coded as ‘Funding’ (Hsieh & Shannon
To add to the rigor of the data, triangulation of measuring instruments was done, e.g. function was determined by the FMA and WSC. All data were collected by one researcher. Generalisability of findings is negatively impacted by the small sample size, convenient sampling method and including only users with access to a telephone.
The study was registered with the Committee for Human Research at the Faculty of Health Sciences, Stellenbosch University (Ethics approval number: S12/08/231). In addition permission to perform the study was obtained from the Eastern Cape Department of Health and relevant institutional heads. Participation in the study was voluntary. Written informed consent was obtained from each participant. All information was treated as confidential.
Of the 30 wheelchair users, six (20%) were female and 24 (80%) male. Their mean age was 43.4 years, with a minimum age of 19 and a maximum age of 82 years. The most common diagnosis was complete or incomplete spinal cord injury (47%), followed by lower limb amputation (23%).
As indicated in
The type of wheelchair issued to participants (
Urban wheelchair designs | Semi-rural wheelchair designs | Rural wheelchair design | |||
---|---|---|---|---|---|
Cruiser® | Adjustable four-wheel folding frame | Econorigid® | Roughrider® | All Terrain Wheelchair (ATW®) | World Made 3® (WM3) |
17 (57%) | 0 | 8 (26%) | 3 (10%) | 2 (7%) | 0 |
Ability to perform functional tasks in the wheelchair according to FMA scores.
Variable | Completely Agree (score 5–6) | Neutral (score 3–4) | Completely disagree (score 1–2) |
---|---|---|---|
Wheelchair features contribute to my ability to carry out daily routines | 17 | 8 | 5 |
Size, fit, support and functional features of the wheelchair match my comfort needs | 21 | 6 | 3 |
Size, fit, support and functional features of the wheelchair match my health needs | 22 | 7 | 1 |
Size, fit, support and functional features of the wheelchair allows me to operate it independent, safely & efficiently | 18 | 8 | 4 |
Size, fit, support and functional features of the wheelchair allows me to reach and carry out tasks at different surface heights | 20 | 6 | 4 |
Size, fit, support and functional features of the wheelchair allows me to transfer from one surface to another | 22 | 6 | 2 |
Size, fit, support and functional features of the wheelchair allows me to carry out personal care tasks | 20 | 8 | 2 |
Size, fit, support and functional features of the wheelchair allows me to get around indoors | 18 | 10 | 2 |
Size, fit, support and functional features of the wheelchair allows me to get around outdoors | 18 | 7 | 5 |
Size, fit, support and functional features of the wheelchair allows me to use personal or public transport | 11 | 13 | 6 |
Ten or more users experienced challenges in the categories of daily routine, operating the wheelchair, performing tasks at different surface heights, performing personal tasks, indoor mobility and outdoor mobility.
As indicated in
Impact of category of wheelchair on function (Kruskal-Wallis;
According to scores from the WSC five wheelchairs (all Cruisers®) were not suited to the environment of the user whilst eight (4x Cruisers®, 2x Econorigids® and 2x Roughriders®) were suitable, and 17 suited the environment partially. Function was hampered for eight users all using Cruisers®, as shown in
Impact of type of wheelchair on function as determined by the wheelchair specification checklist.
When assessing function during completion of the WSC it was found that more than half (57%) of the participants were unable to propel the wheelchair on even terrain, up and down an incline, or manoeuvre up and down a curb.
Comparison between wheelchair specification checklist scores and wheelchair design (Kruskal-Wallis;
All ten therapists who participated in the study indicated that they prescribed the basic four-wheel folding frame design (Cruiser®) most often. According to emerging themes this practice could mainly be ascribed to a lack of funding. Other factors that played a role included insufficient knowledge and skills, sub optimal assessments, inappropriate prescription, no design available on national tender that met all the needs of users, and user choice.
A lack of funding resulted in therapists prescribing cheaper designs, even if less appropriate than others, to increase their ability to provide more users with wheelchairs:
‘It's a moral dilemma – something is better than nothing, so you end up issuing what you have available instead of what is most appropriate.’ (Participant 8)
‘The restricted budget is a massive problem. A letter of concern was submitted through the region's Wheelchair Advisory Committee to the Rehabilitation Manager last year about this. No reply yet. We submit statistics on wheelchair orders every week to the CEO of our hospital, so that they are aware of the waiting list.’ (Participant 9)
‘I always think of the price before I order a wheelchair due to the budget constraints. I think before I order a specified wheelchair if it's not life changing, because those wheelchairs (wheelchairs with designs for semi-rural and rural use) are more difficult to recycle (re-issue to another user in the event of the first user passing away).’ (Participant 5)
Insufficient funding caused waiting periods in excess of 18 months:
‘Patients don’t get a wheelchair at the time of prescription, and two years later they probably need something completely different.’ (Participant 2)
‘By the time you receive the wheelchair and issue it the prescription isn’t accurate anymore because the patient and their circumstances have changed.’ (Participant 6)
Lack of funding seems to cause inappropriate prescription that negatively impacted posture, function and wheelchair durability:
‘Poor funding for wheelchairs makes it impossible to issue the correct wheelchair at the appropriate time because there is such a long waiting list.’ (Participant 3)
‘In 2010 there was a gunshot wound patient who was put into a recliner wheelchair because it was all that was available. I saw how bad the wheelchair was for his posture and for his health. It was shocking.’ (Participant 2)
‘It's always so sad to see young or active clients going home in cruisers because it's the only wheelchair that is available at that time, sometimes it's not even the right size!’ (Participant 10)
‘Seeing Cruisers (basic four-wheel folding frame wheelchair) being returned or brought in for repairs and realising that they are not good enough for the harsh environments clients live in.’ (Participant 1)
‘Wrong prescriptions by other therapists and then I had to issue the wheelchair, and I knew the patient was going to be stuck with that wheelchair. I couldn’t just order them something more appropriate because the budget doesn’t allow that.’ (Participant 8)
Some of the participants considered that lack of training and, therefore, a lack of appropriate skills amongst prescribing therapists caused problems to prescribing the most appropriate wheelchair design:
‘Yes, Cruisers (basic four-wheel folding frame wheelchair) are being ordered too often. It's a habit we have gotten into because we don’t know other wheelchairs, especially the newly qualified staff – their experience start with Cruisers and then they get stuck.’ (Participant 4)
‘Not enough product training from suppliers.’ (Participant 10)
Therapists reported, upon doing a home visit after issuing a wheelchair, that the wheelchair they had prescribed was completely inappropriate for the recipient:
‘I did a home visit and saw that the 20’ wheelchair couldn’t get into the bathroom or fit through the doorframe.’ (Participant 5)
‘(I) issued a wheelchair to a tetraplegic patient, and when I did a home visit (I saw) the patient couldn’t move around inside his house with this big wheelchair because the house was too small.’ (Participant 7)
Two (7%) of the users reported having had a home visit from a therapist or other medical professional. Therapists ascribed the lack of home visits to a shortage of transport and staff shortages.
Therapists felt that the wheelchairs currently available on tender do not necessarily meet all the needs of the wheelchair users:
‘…[
‘If you issue a rural wheelchair to the patient their house is too small for it and transport is a big problem.’ (Participant 2)
‘The wheelchairs on tender are good, but environment where the patient lives makes it very difficult to select a wheelchair.’ (Participant 8)
‘The patient is very restricted in terms of transport – they want a folding wheelchair.’ (Participant 10)
‘[
‘Access is a big problem and therefore patients often don’t want anything but a standard cruiser.’ (Participant 8)
Whilst the majority of users perceived themselves to be capable of performing all functional activities in the wheelchair, categories pertaining to daily activities, wheelchair dexterity and mobility created challenges for a third or more users. As the purpose for providing a wheelchair is to enhance function and mobility this finding remains worrying. The reasons for this can be multiple and might include a lack of training and a lack of physical ability (Vegter
Users using a basic four-wheel folding frame design experienced poorer overall function than those using other wheelchair designs. This may be because this design is not suitable for active users nor for outdoor use on uneven terrain. In addition this design provides little scope for biomechanical adjustments that could enhance user function (PGWC DoH
The four-wheel design with adjustable settings and fold-down backrest, which was issued the second most often, is considered appropriate for active wheelchair users in urban settings. The adjustable wheelbase of this design can assist with reducing the weight carried by the front castors and, thus, increase manoeuvrability of the wheelchair. In addition, optimal access to the rear wheel and, thus, more effective propulsion can be achieved through the adjustable settings. It is the experience of the authors that its greater manoeuvrability, lighter weight and transportability make this the wheelchair design of choice for many young, active users such as younger persons with spinal cord injuries (Dryden
The ATW® may be the more appropriate wheelchair for users living in a rural setting despite its potential access limitations in small houses. This will, however, need to be explored further as only two ATW®s were used by participants in this study. It is disquieting that none of the participants living in a rural setting were issued a World Made 3® that was specifically designed for rural use. The overall size of the WM3® and the difficulty of transporting it (PGWC DoH
Transport created a big challenge for user participants in the study. Other South African studies have reported similar findings (Chakwizira
The majority of users in this study, living in rural and semi-rural settings, received wheelchairs designed for urban use. Therapists reported that wheelchairs designed for urban use were issued most often in this setting. The findings of this study suggest that this design was not always inappropriate to the users’ environments and supports Vegter
A comprehensive assessment is required to determine appropriate design and should include a thorough investigation of the environments in which the user functions. This most likely will require a home, community and or work assessment visit (PGWC DoH
The results show that 17 participants were using a wheelchair that suited at least one aspect of their environment. Thus, a trade-off was needed in some circumstances; mostly between the need for a compact and manoeuvrable design in small indoor spaces and for transport, but a sturdy, stable design for rough outdoor surfaces. Therapists realised that the wheelchairs currently available on tender were not able to address all the needs of some users. This sentiment is supported by findings from Øderud (
Amos & Winter (
Rural and semi-rural devices are more expensive than the basic, four-wheel, folding frame design and ordering these devices will deplete the wheelchair budget faster. Therapists indicated that they issued cheaper designs to ensure that more users are assured of receiving a wheelchair. Whilst this argument might seem reasonable, exhaustion caused by trying to propel a wheelchair, designed for urban use, over rugged terrain with narrow, steep footpaths and roads, might cause users to discard the wheelchair even if it is their only means of mobility (McAdam & Casteleijn
The non-parametric sampling procedure compromised the external validity of the study and generalisability of findings. Sample size was dictated by time and cost implications rather than power analysis. Thirty participants are too few to allow for extensive sub-group analysis in order to explore relationships between variables.
More comprehensive assessments, including home and work visits, are recommended to allow for more appropriate selection of wheelchairs. In addition users functioned in two very distinct environments which require a wheelchair that is stable and functional on uneven terrain, yet manoeuvrable and compact in small dwellings. Further training of therapists and users is recommended, about the designs offered by the wheelchairs currently on tender and research into wheelchair design for promoting independent mobility in rural settings. Research is also recommended that looks into the long term cost and quality of life implications of providing a suitable wheelchair, versus providing a cheaper option that is less suited than others to the environment.
The provision of wheelchairs, more suitable for urban use, to users living in rural settings might have impacted the functional outcomes of users adversely, especially in instances where the standard folding four-wheel design was prescribed. Reasons for prescribing the basic four-wheel folding frame wheelchair were being predominantly pragmatic, driven by cost, extended time-to-issue and fair distribution. User preference and different environmental needs experienced by the same user created challenges which the current system might be unable to address.
The authors would like to thank Prof M. Kidd, Statistician at the CSC SU, and the participants (wheelchair users and therapists) for their time and valuable input. This project received funding from the Harry Crossley Fund.
The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article.
S.V. (Stellenbosch University) provided guidance during the research; was responsible for the conceptual framework and writing of this article. S.D. (Stellenbosch University) was involved in project design; data collection and analysis; and contributed to writing this article. M.U. (Stellenbosch University) was involved in project design; made conceptual contributions; and was responsible for editing this article.
BScOT; Manager CE Mobility EC.