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Aug 27

Wheelchair Setup

We are wondering if you have any thoughts regarding the set-up of wheelchairs for a person with amputation. Specifically, should the wheels be set further back to prevent tipping for anyone with a lower limb amputation? Is there a difference depending on the level of the amputation (below knee vs above knee) or any difference according to whether it is a unilateral or bilateral amputation?

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  1. Tony

    Speaking from a physics perspective, I would think that the more mass or weight that is ‘lost’ from the front, the further back the wheelchair user’s centre of mass is, and more likely the chair is to tip backwards. So for a bilateral transfemoral amputee, it is much more crucial to have the rear wheels set back than it is for a unilateral transtibial. While I have seen a unilateral transtibial amputee manage in a standard chair, the recommendation does seem to be to have their wheels set back too. Many factors can come into play besides level of amputation, for example:
    * Adding a pressure relieving cushion raises centre of mass as well, increasing instability and likelihood of tipping.
    * Even the loss of weight of foot rests adds to risk.
    * Height of the amputee in sitting, with taller amputees more at risk.
    * Consideration of trunk control and sitting balance, such as ability to sit forward, and not lean back.
    * Where will the chair be used, for example going up ramps increases risk of tipping backwards, but rear wheels set too far back make it more difficult for getting the front wheels over small steps or obstacles.
    So generally I would think the rear wheels do need to be set back, but each person should be assessed on their needs, particularly those who are going to be long-term users or less able to walk.

  2. Craig

    In addition to the characteristics Tony has raised, anti tip bars may need to be considered for bilaterals but each case needs to be assessed on its merits. I would also advise that the ease of movement and removal of footplates and arm rests should be considered in view of the likely comorbidities of our amputees requiring wheelchairs e.g. diabetics with poor skin condition and circulation / sensation in their feet/legs which are at risk of trauma, reduced dexterity in the hands and fingers to manipulate the chair. Many of the chairs these days seem to have footplates that, when swung away, will not allow free travel of the front (smaller) wheels to position the chair correctly for transfers.

  3. lynette wakefield

    Down the track some unilateral amputees do manage quite well without this modification. Long based wheelchairs are harder to manoeuvre and some amputees do find this to be an issue. They do have to have good balance and wheelchair skills and the right body shape to cope with this and know their own and their chairs activity limits. I would have concerns about not using a long based chair with almost every bilateral amputee I can think as I think the risks of falls in this group is quite high irrespective of their balance and wheelchair skill level and wheelchair use purely due to the loss of body mass and greater shift of their centre of gravity backwards.

    Anti- tippers are also an option to consider on the wheelchairs of amputees.

    In short wheelchair prescription should be done on an individual basis to meet the needs of each amputee

  4. Judy Davidson

    Regarding Enable and use of amputee axle plates. There are multiple issues here. Yes it does relate to the weight being transferred back. There are several major disadvantages to amputee axle plates:
    *It increases the wheel base of the chair and may make it unable to get around corners in a small unit.
    *It requires extra shoulder extension to push the chair and hence can cause additional problems for the user in terms of short term and long shoulder pain.

    I do not use amputee axle plates ever for transtibial unilateral or trans-femoral unilateral. In all these years I have not had a problem. I might use it for a unilateral hip disarticulation but not if we can teach them to lean forward to compensate. Hence dementia or confusion would make this difficult but these would usually be cancer and probably not PVD and hence not as old. I would not use it for trans-tibial bilateral who wear their prostheses a lot especially when outdoors. The amputees probably do not need for use indoors because the real chance of tipping is outdoors going up a slope, not indoors.

    I would reconsider if the person was obese with the weight above the hips because they would then have their weight set back even more.

    I would probably use it for a bilateral trans-femoral because, under the prosthetic limb services they would not be entitled to a C leg and hence prosthetic use is highly unlikely except for cosmesis and most people do not use legs for cosmesis a lot.

    You also need to consider what happens to a unilateral trans-tibial amputation who then undergoes amputation of the other leg. Do you prefer to supply a new wheelchair that might be required or use a chair initially that has options. Because surgery to save legs is better now than 20 years ago I suspect those people are few and far between.

    It is important not to become so risk conscious that we diminish the amputees capacity to participate in life by making the wheelchair use harder than it needs to be. Life is here to be enjoyed not to be worried about risks. Pain clinics spend so much time overcoming fear avoidance and catastrophising we do not want to do this with amputees as well. We can teach the family about the problem.

    The problem of the transfer of weight can be overcome by weighting the footplates (assuming they use these – bilateral trans-femoral probably will remove the footplates). Again this makes it slightly harder to push. In terms of what Enable buy to meet the needs of these people I would suggest you consider:
    *Buying chairs where there is an option to use amputee or standard axle plates on the same chair. This usually sets them back about 8 cm.
    *Buying chairs where there is plate on the axle that allows the wheels to be moved. This is not easy to be moved but the distributors do do it. This allows for the wheel to be set back 3 or 4 cm which is probably sufficient for most people without the additional 4 cm which just makes everything more difficult.
    *Using anti-tip bars (or one anti-tip bar) but this makes it harder to go up a step.

    Those chairs may all be more expensive and you might prefer to have specific purpose ones that are cheaper. Clearly that is a financial decision rather than clinical. Again you need to consider the requirement for stump supports if people with trans-tibial amputations are going home very early. It is my opinion that once they have their prosthesis and are walking they do not need the stump supports but some patients like or want them.

    It is certainly worth ongoing discussion especially amongst rehabilitation teams with young OTs who are often doing the prescription. It might be that some guidelines and issues are worth developing.

    Judy Davidson
    Occupational Therapist in Amputee Rehabilitation

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