INTRODUCTION
For people who spend most of their day in a wheelchair an active user chair is one that offers adjustability and manoeuvrability and can be configured to meet the specific needs of the user. These chairs provide the user with independence and mobility and have helped to dispel negative attitudes towards wheelchairs.
This type of chair is often regarded as sporty and suitable only for young, fit wheelchair users who play sport and can push for miles. Active user chairs meet these needs very well but in many ways they are as suitable for the older or possibly frailer user who is finding it increasingly difficult to propel a standard manual wheelchair.
Active user chairs are more flexible than the standard chairs and can be adjusted to meet the individual requirements of users so that he/she can achieve the maximum amount of mobility. They have quick release wheels, multiple axle positions and frames that are available in a wide variety of sizes.
Originally designed for sport, they are lighter than standard chairs and are therefore easier to propel and transport. Also, the large rear wheels can be brought forward to alter the weight distribution so that the user needs much less energy to propel the chair.
In addition, the above features make it much easier for someone else to push these chairs, so that they are being used increasingly as attendant-propelled chairs.
Remember that one wheelchair may not provide all the answers. Compromises may have to be made once the priorities of each need have been weighed up. Some users may require two different types of wheelchair, each for a different range of activities - one self-propelled wheelchair for everyday use and another for sports purposes; or a self-propelled wheelchair for use indoors for short distances, and a powered electric wheelchair for long distance outdoor use.
The information contained in this document is strictly for information purposes only. There are hazards with all equipment and the suitability of any solution is totally dependent on the individual. It is strongly recommended to seek professional advice and assistance before you consider buying any type of equipment mentioned in this Information Sheet.
For up-to-date information on specific products and suppliers in Ireland, visit the ‘Products and Suppliers’ section of the Assist Ireland online database (www.assistireland.ie). The information in this resource can also be accessed using the telephone support service on 0761 079 200 during office hours.
WHAT DOES THE USER NEED?
A stable seating base
All wheelchair users who propel themselves need a comfortable, stable seating base. They cannot be expected to propel efficiently if part, or all of their energy is being channelled into trying to sit up straight. Many users waste valuable energy either shifting or fidgeting in the chair to maintain a comfortable posture or constantly heaving themselves up as they slide forwards or sideways. It is important that users are able to save as much energy as possible so that, having propelled themselves from A to B, they still have enough energy to carry out whatever activity is necessary. For people with mild to moderate seating difficulties, the correct size and positioning of the wheelchair seat unit components may be all that is needed to provide them with a stable seating base. For wheelchair users who do not have the ability to sit unaided, and those who lose that ability, perhaps as the result of a progressive disabling condition, a wheelchair that is used in conjunction with a more sophisticated seating system may be needed.
A stable seating base can be achieved if the following factors are considered:
Seat size
Maximum stability will be achieved if the body of the user fits comfortably into the chair seat. If the seat is too wide, the user may not sit symmetrically; if the seat is too narrow, there is a risk of pressure sores.
If the seat is too short, the full length of the thighs will not be supported and too much pressure will be transferred onto the buttocks.
If the seat is too long, a pressure area may develop behind the knee, and the user may not get adequate support from the backrest.
Active user chairs are often supplied with a range of seat depths.
Shape and angle of seat
The seat needs to be level. A sagging wheelchair seat canvas will cause users to sit asymmetrically with their thighs and knees rolled together. This will cause undue pressure and shearing - the term used when the outer layer of skin is pulled in a certain direction while distorting and restricting the underlying blood vessels. This may lead to pressure sores.
The tension of the seat canvas on many active user wheelchairs can be adjusted to keep the seat level. If this adjustment cannot be made, a board straight onto the frame or integrated into a cushion can be used.
The stability of the pelvis is determined by the angle between the thighs and the trunk, which, in turn, affects the ability of the user to maintain a good-seated posture. An angle of 90° is considered best for most people undertaking daily activities. Using a contoured cushion or ramped seat, ie very slightly lower at the back to accommodate the shape of the buttocks, is the easiest way of achieving this.
Some wheelchair users sit with the seat sloping backwards and downwards and with the backrest slightly inclined forwards; this secures their pelvis more firmly and is called bucketing. It may, though, cause greater strain on the spine.
All wheelchair users should sit on a cushion that has been chosen at the same time as the wheelchair and fits the wheelchair seat. Full-time wheelchair users will probably need a pressure relief cushion; occasional users may only need one for comfort.
To fully stabilise the lower body, the foot support needs to be considered next.
Footrest length
If an angle of 90° between the hips and thighs of the user is achieved, most people will be comfortable if their knees are also at an angle of approximately 90°.
The footrests on the wheelchair should be set so that they support the legs and feet at a height where the undersides of the thighs are evenly supported along the length of the seat. If the footrests are too high or the seat too low, the knees of the user will be higher than the hips so that pressure under the buttocks is increased.
If the footrests are too low, or the seat too high, the knees of the user will be lower than the hips and pressure will build up under the thighs and behind the knees.
Footrest angle
For users with long legs, some wheelchairs have footrests that are set out at a wider angle in front, so that the leg length can be accommodated without hindering activities such as kerb climbing. Some active user wheelchairs have a choice of two or three footrests, each of which is set at a different angle.
Footplate angle
The angle of some footplates (ie the flat plate at the end of the footrest on which the feet are placed) can be adjusted on some chairs. Feet, which can be very strong stimulators of muscle contractions of the whole body, may cause extension patterns or tremor spasms in the legs. This is a common problem experienced by users with MS (multiple sclerosis). By setting the footrest/footplate angle at less than 90° the feet of the user can be prevented from slipping forwards and down off the footplates. This also stretches the calf muscles and may inhibit extension patterns and spasms.
Backrest height
The backrest should be high enough to stabilise the upper lumbar region. Above this level the backrest height is a matter of individual need and/or personal preference.
Some users find that if they have a stable seating base they only need a backrest that comes halfway up their back. Although not as supportive as one that extends to just below shoulder height, it enables the user to propel without restriction. This is a compromise that many active users find most comfortable.
The only disadvantage of a wheelchair with a lower backrest is that the pushing handles are often too low for the attendant to push comfortably. Some active user chairs have adjustable height or tall, removable push handles to overcome this problem.
Backrest shape and angle
Most users will benefit from a backrest with an appropriately shaped lumbar area. This, combined with a suitable backrest angle, provides support and balance for the upper body.
Many active user chairs are provided with backrest angle plates that make it possible for the backrest to be angled forwards by a few degrees to provide maximum support. These plates are useful, as the sitting posture of a wheelchair user will often change over a period of time.
Arm support
In theory, if a person has a stable seating base then he/she should not need armrests.
Armrests should not be used to help someone stay in the chair - if this is the case, the seating base of the user should be reassessed. A more sophisticated seating system may be necessary.
However, armrests provide useful rest and stabilising positions for users who tire rapidly and/or those who have weak upper limb and neck muscles.
Armrest height
When armrests are properly adjusted, they should support the forearms of the user comfortably with the elbows at 90°. If they are too high, the shoulders of the user will be hunched; if they are too low, users will tend to slump to one side.
Armrests also provide an appropriate surface to push down on for users who stand up directly from their wheelchairs. However, they do make approaching tables and work surfaces difficult and often have to be removed for transfers.
Users whose wheelchairs do not have armrests should consider clothes guards made of stiffened material, which protect clothes from some of the dirt from the wheels.
A stable seating position will not only benefit users physically, but also psychologically because, if they are sitting straight, their clothes will hang correctly so that they will look and feel better.
Once the seating base of the wheelchair has been sorted out, the next thing to consider is the type and set-up of the wheelbase. It is often thought that the weight and the material from which the wheelchair frame is made are the main factors, which affect the manoeuvrability of the chair. In fact, it is the size and position of the wheels. These affect the weight distribution, the rolling resistance and, therefore, the manoeuvrability and the amount energy needed to propel the wheelchair.
A chair that is easy to manoeuvre
The ability to back-wheel balance has an important effect on manoeuvrability. To do this, the user balances the chair on the large rear wheels so that the front castors are lifted clear off the ground. This makes it easier for him/her to negotiate kerbs or avoid small obstacles such as an uneven surface or grids.
Standard wheelchair tipped back
Active user wheelchair in tipped position
Tippiness is the term sometimes used to describe the ease with which the chair can be made to achieve this balance.
The position of the wheels affects the ease with which a chair can be tipped. The wheels on standard wheelchairs tend to be set quite far back so that more leverage, and therefore more energy, is needed to lift the castors off the ground.
To find the balance point of a standard manual chair, the castors have to be lifted quite a long way off the ground so that the chair is leaning backwards at quite a dramatic angle! Active user chairs wheelchairs have a multi-adjustable axle plate which allows the wheels to be set further forward under the body of the user.
This not only affects the leverage, making it easier to lift the castors off the ground, but also the distribution of weight over the wheels, which, in turn, affects the tippiness of the chair. The higher the percentage of weight placed over the back wheels, the easier it is to lift the front castors off the ground. When the rear wheels of an active user chair are moved forward, more weight is placed over them. Standard wheelchairs have a weight distribution of 40:60 front to back wheel ratio, high performance wheelchairs have a 30:70 ratio.
This weight distribution also affects the rolling resistance, ie how much energy is lost during pushing. This can be calculated by dividing the weight of the wheelchair by the area of the wheel that is in contact with the ground. The area of large rear wheels in contact with the ground is approximately twice as much as that of small front castor wheels (eg 10mm: 5mm).
The average active user wheelchair weighs 12kg and the weight is distributed 30:70 front to back wheel. Calculated in the way described above, this type of wheelchair has a rolling resistance of 1.5.
If a standard, self-propelled wheelchair weighs 18kg, the weight is distributed 40:60 front to back so that the rolling resistance of this type of wheelchair is 2.5.
To achieve the minimum rolling resistance, therefore, as much weight as possible needs to be placed over the larger back wheels without compromising stability.
An energy-conserving chair
Most standard self-propelled wheelchairs have a 20in-22in (51cm-56cm) rear wheel. Active user chairs usually have 24in (61cm) wheels but can have ones of 26in (66cm). Therefore, using the above calculation without taking into account any other factors, active user wheels are shown to have less rolling resistance since a larger area of the wheels is in contact with the ground so that the chair is easier to propel.
The length of the wheelbase will also affect the amount of energy needed to manoeuvre a chair. Active user chairs with their wheels set further forward have a shorter wheelbase and therefore a shorter turning circle so that the user needs less energy to turn the chair.
The position of the rear wheels also affects the amount of energy needed for propelling. If the wheels are set with their axles in a vertical line with the shoulders of the user, maximum push with minimum effort can be achieved. This reduces the amount of wear and tear on the shoulder joints of the user.
A chair that is easy to steer
If the rear wheels of a chair can be cambered (ie angled towards the chair at the top), this will reduce dramatically the effort required to propel a wheelchair across a slope in a straight line. Anyone who regularly pushes outdoors and has to tackle pavements will therefore benefit from cambered wheels.
Less effort is needed to keep the wheelchair in a straight line if its wheels are cambered, and the ease with which the user is able to turn the wheelchair is also increased. For everyday use, camber up to 5° is acceptable. Beyond this, the chair often becomes too wide so that going through narrow spaces, eg doorways and small bathrooms, becomes difficult.
People who use a wheelchair for sport may camber the wheels at more than 5° so that they can guide the chair with greater ease and accuracy.
A chair that is easy to transport
Wheelchairs can be cumbersome and heavy to lift into a car. Chairs with a cross-bracing mechanism underneath can be folded and made lighter if the leg rests and armrests and quick release wheels are removed, where possible. Rigid-framed chairs can also be dismantled if the quick release wheels and armrests are removed and the backrest, etc are folded down. There are some rigid-framed chairs designed with minimal metalwork beneath the seat. These are body-hugging frames, which make it easier to bring the chair across the body when loading the chair into the passenger seat of a car.
A chair that is versatile/adaptable
The body shape and size of a person, as well as his/her disabilities, do not always remain static. As changes occur, the wheelchair requirements may also change. Active user wheelchairs have interchangeable component parts which make them more versatile and adaptable.
A chair that meets the needs of carers
Some users of self propelled wheelchairs are independent, and can get themselves in and out of cars and buildings. However, others may rely on someone else to load the wheelchair in and out of the car, or maybe to push them round in it, at least for part of the time.
If the person who is pushing the wheelchair is also the carer, it is especially important once the needs of the user have been met that as many as possible of the needs of the carer are also taken into account. By reducing energy expenditure and increasing the manoeuvrability and transportability of a chair, life will be made easier and the risk of back injury minimised. In addition, the carer may be able to take the wheelchair user to a great many places that had previously seemed either difficult to get to, or even inaccessible.
A chair that makes the user look good and feel confident
A chair that is energy efficient and looks aesthetically pleasing will inspire confidence in the user.
PROVISION OF EQUIPMENT
Medical Card Holders
Equipment for people with disabilities, sometimes referred to as aids and appliances, is usually supplied free of charge to medical card holders. The card holder must first be assessed by the relevant therapist who can recommend and prescribe the most suitable equipment.
Long Term Illness Card Holders
People who have one of the conditions listed as qualifying under the Department of Health’s Long Term Illness Scheme may be eligible to receive items of equipment, essential for the primary condition, free of charge. Assessment by the relevant professional is required.
Hospital Treatment
People in hospital may have aids and appliances provided free of charge when they are prescribed as part of in-hospital treatment in a public hospital.
Health Insurance Schemes
There are three main companies offering private health insurance in Ireland. These are:
- Voluntary Health Insurance (VHI)
- BUPA
- VIVAS Health
All three companies provide members with cover for a limited number of aids and appliances under their out-patient schemes. A list of approved appliances is available on request. A claim for the reimbursement (part or full) will be subject to a member’s out-patient excess. Medical certification is usually necessary. Contact your health insurance company’s Customer Services to check if a particular appliance is covered by your policy.
Some employers have their own special health insurance schemes which provide cover for their employees. The employee’s family is also often covered. Check with the employer to see what, if any, equipment is covered under the scheme.
ASSESSMENT
Depending on the type of equipment required, a qualified therapist will assess the individual and make a recommendation to the body responsible for the provision of the equipment or to the person or agency who has requested the assessment. Generally the following applies, but the assessment process and provision may vary in different parts of the country.
- Occupational therapists will assess for aids to daily living – these include wheelchairs, mobility aids, specialised chairs, bath, shower and toilet aids, stairlifts, hoists etc
- Physiotherapists will assess for movement, strength and balance training equipment, walking aids and exercise devices
- Speech and language therapists will assess for communication, speech therapy, and training aids
- Other relevant therapists and specialists may also be involved in carrying out assessments, depending on the equipment or appliance required.
All the different therapists described above are based in hospitals, community care areas, and with various voluntary agencies. For more information, contact the Community Care section of your Health Services Executive area or the relevant hospital department as appropriate.
SHORT TERM LOAN/HIRE OF WHEELCHAIRS
Quite a variety of equipment, including wheelchairs, hospital beds, hoists and a variety of walking aids, can be hired for daily, weekly or monthly periods. Many of the companies and voluntary organisations that provide this service can be found in the Golden Pages under ‘Disabled Persons Products & Services’, or by contacting your local public health nurse or community occupational therapist.
Before you choose to hire, consider the following:
- Does the company provide a delivery and/or collection service and, if so, are there any additional charges?
- Does the company ask for a deposit and is it refundable?
- If hiring long term, is the vehicle subject to a six-monthly service and, if so, will a replacement wheelchair be supplied in the mean time?
- Who is responsible for maintenance if you have a puncture, for example?
- If you are hiring for holiday use, are you permitted to take the vehicle overseas? Are there additional charges, and/or an increase in the deposit needed?
- Are you obliged to take out insurance? Is this included in the price, and what does the insurance cover?
- When hiring a wheelchair, make sure you understand how to operate it and feel confident using it; and make sure you receive instructions on how to charge the batteries (if required) and carry out other simple maintenance.
Shopmobility
A Shopmobility scheme operates in Liffey Valley Shopping Centre in Clondalkin, Mahon Point Shopping Centre in Cork, Dundrum Town Centre in Dublin and Whitewater Shopping Centre in Newbridge, Co Kildare. This scheme enables anyone to get the loan of a manual wheelchair, a powered wheelchair or a powered scooter while shopping. This is a free service and helpful for anyone who finds shopping a tiring experience. To avail of this service, you must have two pieces of identification with you including photo ID. It is advisable to ring beforehand, particularly coming up to a holiday period or a bank holiday weekend (see Useful Addresses).
Some other shopping centres also have manual wheelchairs that they loan out to customers. Contact Customer Services of the shopping centre to check on the availability of this service.
PURCHASE OF EQUIPMENT
Private Purchase of Equipment
Private purchase may be necessary if the user is not eligible to obtain the necessary equipment from the local area health services. Some people may also choose to buy privately because they want the wider choice of equipment available on the private market.
The purchaser has the option of:
- personally funding the cost of the equipment
- applying to charities/benevolent funds etc for funding
- buying second-hand
- checking with your health insurance company, if a member, to see if, or what, reimbursement is available.
Private Purchase – Applying for a VAT Refund
VAT paid on certain equipment which is privately purchased for use by a person with a disability can be reclaimed from Revenue. The relief applies to VAT on the purchase of goods which are aids and appliances designed to assist a disabled person to overcome a disability in the performance of their daily functions. Most aids to daily living and communication aids are included. Goods designed for leisure purposes are not. An invoice clearly stating the VAT content of the total amount paid must be included with the application. Form VAT 61a is available from Revenue or can be downloaded from their website (see Useful Addresses).
Funding from charitable sources
If you have little or no disposable income, but do not have a medical card, you could consider applying to a local charity, benevolent fund or occupational fund for financial assistance. Some such organisations have budgets for exceptional cases or needs and requests will be dealt with in confidence.
Private Occupational Therapists
Occupational therapists in private practice can carry out assessments in the home or workplace, and if home modifications are being considered, provide a report detailing the recommendations. It is important to ensure the therapist is experienced in relation to your particular needs. Make sure to discuss fees before engaging anyone’s services, and also check what the assessment fee includes (or does not include). The profession’s representative body, the Association of Occupational Therapists in Ireland (AOTI), keeps a list of contact details of member occupational therapists working in private practice in Ireland. This list is available from the AOTI (see Useful Addresses).
Private Physiotherapists
Physiotherapists can assess for movement, strength and balance training equipment, walking aids and exercise devices and recommend accordingly. If you wish to consult a physiotherapist you can go directly to your local chartered physiotherapist or ask your GP to refer you. It is important to ensure the therapist you consult is experienced in relation to your particular needs. Chartered physiotherapists work in hospitals and in the community where treatment is covered under the public health service. They also work in private practice and can be contacted through the profession’s representative body, the Irish Society of Chartered Physiotherapists (see Useful Addresses), or through the Golden Pages.
Second-hand equipment
Buying second-hand can be a cheaper way of finding a solution to your mobility difficulties but, since choice is more limited, you must make sure that you do not compromise on your essential requirements. Also check that what you are buying is in good working order. You do have certain consumer rights when buying second-hand; for example, the seller must accurately describe the product he/she is selling; and you should be made fully aware of any faults that need attention. If possible, obtain a written description of the product from the seller before you buy so that, should you find any faults, you can get your money back more easily.
There are basically two sources of second-hand equipment: equipment retailers and private individuals.
Some commercial suppliers also buy unwanted or little used equipment, recondition them, and then offer them for sale with a short guarantee of, for example, three months. Buying second-hand from a retailer is generally more expensive than buying from a private individual, but the equipment is likely to have been serviced and should be in reasonable working order.
Buying from a mobility equipment retailer
Some commercial suppliers of wheelchairs also buy unwanted vehicles, recondition them, and then offer them for sale with a short guarantee of, for example, three months. Buying second-hand from a retailer is generally more expensive than buying from a private individual, but the wheelchair is likely to have been serviced and should be in reasonable working order.
Buying from a private individual
Some mainstream magazines and several disability organisations publish journals that contain advertisements for second-hand equipment. If you are buying second-hand from a private individual, you must make sure that the wheelchair has been regularly maintained, that you also receive accompanying literature, for example a care manual; and that you receive instructions on how to control and steer the wheelchair. You will also need to find the local company able to service your wheelchair and carry out future repairs.
TRY BEFORE YOU BUY
Wheelchairs are expensive so it is essential that you do not rush into buying a vehicle that you later find is not entirely suitable. If the wheelchair is being provided by the health services, the occupational therapist and wheelchair service provider will be able to assist you in selecting the most suitable wheelchair for you.
Before buying privately, it is strongly recommended that you seek the advice of an occupational therapist on the suitability of the wheelchair to your condition or situation. It is also recommended that you try out and compare a range of different wheelchairs if possible.
You can arrange to visit a supplier’s showroom (if they have one). Contact details of suppliers can be found under ‘Disabled Persons Products & Services’ in the Golden Pages and some may have a website with details of their products and services which you can view online. Another source of information on suppliers of assistive technology, aids and appliances is the Access Directory. This directory is produced commercially each year and copies are widely available (see Useful Publications.)
Sometimes suppliers organise exhibitions of different types of equipment in various locations around the country allowing people to see and try equipment. These exhibitions are often advertised in the local paper or on local radio. You can also request to be put on a supplier’s mailing list so you will be notified if there is an event being held in your area.
Some companies will give equipment for a try-out period before purchase. Enquiries should also be made about maintenance (if it will be required), maintenance contracts (if relevant) and whether a user manual is provided with the equipment (essential).
When purchasing from any supplier, it is important to remember that it is their business to sell. There may be several suppliers of that particular piece of equipment or different manufacturers of the same type of equipment, so always shop around.
Before you commit to buying, check the following:
- What is the delivery time?
- Will the wheelchair arrive readily assembled?
- What guarantee is available?
- What after-care service is offered?
- How much is the call out charge?
- Will spare parts be brought to the home?
- If the chair has to be taken away for repairs will a 'loan chair' be offered?
- Does the manufacturer offer insurance schemes?
