RESNA 28th Annual Conference - Atlanta, Georgia
Randy Bernard, MA & Johanna Anderson, MPH
CATEA, Georgia Institute of Technology & Emory Univ. Center for Health in Aging, Atlanta Georgia
Nursing home and assisted living facility residents who rely on manual wheelchairs as their primary mode of transportation find ‘depot’ chairs to be problematic in use and comfort. We conducted focus groups with residents and staff to better understand the needs of the elderly user and the problems associated with propulsion and comfort. The problems identified by all groups were similar yet the emphasis varied. Residents were evenly divided on which is more important: comfort or propulsion. Unexpected responses from both groups broadened our perspective on the importance of features and functions of the wheelchair for the elderly and staff.
Elderly, wheelchair, propulsion, comfort, user needs.
It is estimated that there may currently be as many as 600,000 elderly wheelchair users in US nursing homes (1). In most cases, the manual wheelchair used by the resident to assist their mobility was not designed to meet their everyday needs but to increase their safety. Specifically, the areas most affecting the use of the wheelchair are the inability of many users to propel themselves independently as well as the discomfort of the seating system. In a study looking at wheelchairs as mobility restraints (2), it was found that only 45% of the residents could move their wheelchair under their own power. Much of this has to do with increasing the safety of the wheelchair by moving the main drive wheels farther back to decrease the likelihood of falling back. Though this may increase the safety of the wheelchair, it reduces the usability due to the limitations of the users range of motion. The push rims also play a large part in the inability to propel independently. For the elderly population, the diameters of the push rim are too small and too slick. One study (3) found that 54% of the elderly users who participated gripped the tire and push rim together and 7% the tire only. This suggests that the hand rims are not meeting the ergonomic needs of the users. The seating system also plays a role in self-propulsion as well as the overall comfort of the elderly user.
Comfort is a very complex topic when you discuss wheelchairs and functionality. By adding a cushion to the seating system, the user is more comfortable as opposed to a sling seat. A comfortable seat has been shown to benefit the user for self-propulsion. Robert Fuchs study (4) found the most frequent unmet need was independent propulsion. He attributed that in part to the users’ seated posture. Posture is directly affected by the seating system being used. When a wheelchair has a sling seat the user has the tendency to slide forward in the seat. This kyphotic posture (5) creates an even greater inability to independently propel due to the body position in relation to the drive wheels. Comfort can also be interpreted as creature comforts, which include, pockets to store personal items and extra padding on exposed metal parts.
What are the manual wheelchair-needs of the elderly person living in a long term care facility. Is there a difference between elder manual wheelchair users in nursing homes and assisted living facilities in terms of what they want/need in a wheelchair?
Focus groups, ranging from 5-8 participants per group, were conducted with residents and staff of 3 nursing homes and 3 assisted living facilities in metro Atlanta. Participants were selected by the facility. Residents were selected based on their ability to comprehend questions and participate in a discussion; family members were invited to accompany residents. Staff was selected based on their experience with residents using wheelchairs. Participants totaled 25 nursing home residents, 17 assisted living residents, 16 nursing home staff, and 19 assisted living staff. The guided discussion identified problems with the use of wheelchairs and recommendations to improve their use and comfort.
The questions for the residents focused on propulsion and comfort which included questions on; method of propulsion, associated pain, hours in the chair, purpose for using the chair, methods of transferring in and out of the chair, seating and cushions, and comfort related to all aspects of the use of the chair. Staff commented on how many residents were in their care, how many used wheelchairs, how many hours residents typically sit in a chair per day and for what purpose the residents used the chairs.
Focus group results gave a clear picture of the needs of both the residents and the staff, which frequently overlapped. The perspective of the staff on residents’ need paralleled what the residents said thus demonstrating that the staff understands the residents’ experience.
Comments relating to propulsion were specific and similar among all groups. The 3 main areas commented on were: 1) chair weight, 2) drive wheels and push rims, and 3) brakes. The weight of the wheelchair was always the first area commented on. Residents wanted lighter chairs to make propulsion easier; nurses wanted lighter chairs so residents needed the staff less; families wanted lighter chairs to more easily load and unload when taking the resident on excursions. Residents identified the location of the main drive wheel as a problem, commenting that the wheel was too far back to reach comfortably and demonstrating this during the focus group discussions. Push rims posed a problem for residents who had arthritis in their hands and limited range of motion in their shoulders. The small diameter of the rim was more difficult to grasp by arthritic hands and low grip strength, which frequently caused the tire to be used as the pushing surface. Complaints about the brakes were numerous among both residents and staff. Brakes were too hard to engage, too difficult to see, too loose and did not keep the chair from rolling or in many cases just did not work.
Comfort and fit of wheelchair were synonymous. Contrary to our team perception of wheelchair comfort as just seated comfort, the residents talked about comfort in fit of the chair to their body. Comfort also included footrests that not only keep the feet from slipping off, which they said often happened, but could also be easily moved out of the way, adjustable armrests, storage for personal items, padding on metal parts, and more comfortable seats, cushions, and backrests. Most of the seating systems were sling backs and sling seats. Only 20% of residents used cushions. On average, residents said they sat in their chairs 8 hours per day with some sitting as much as 14 hours. When we asked the residents, which was more important, comfort or ease of propulsion the responses were evenly split.
This focus group study of elderly wheelchair users living in long term care facilities was conducted for the purpose of better understanding the needs of the users in comfort and function. Our team was interested in the comfort of the wheelchair both during propulsion and when sitting. Our intentions are to rely upon the expressed needs of the user during the development of an improved wheelchair for the elderly. We collected more valuable information than anticipated. Some of our initial concepts of what was needed or what was important changed and additional ones were created.
Comfort and propulsion are the two major issues for elderly wheelchair users, as expected. We did not expect to hear residents equate comfort with fit and function of their wheelchair. We anticipated hearing the residents talk about seating and comfort, but we were surprised by the consistent reference to storage of personal and private items as a comfort issue as well as issues with other wheelchair components.
Fitting the wheelchair to the person is the best way to improve the comfort and function. Unfortunately, the ‘depot’ chairs that most nursing homes can afford are non-adjustable. Although better footrests, adjustable armrests, added pockets, extra padding, better cushions are currently available on wheelchairs and can be added as after market components, budget restrictions in nursing homes do not allow for them.
The problem with brakes that all groups identified included, they did not function as intended, could not be visually identified from other wheelchair parts, and were too difficult to use for many of their intended users. Brakes are a major problem, not only in wheelchair satisfaction but also and more importantly in the resident safety.
Professionals in the field of rehabilitation recognize that the wheel location of the ‘depot’ wheelchairs is inappropriately placed for the elderly. The majority of elderly users have reduced strength and range of motion in their arms and shoulders and find it difficult to propel this standard chair thus leading to loss of independence and more dependence on others, family and staff.
This research is supported by the U.S. Department of Education, NIDRR, Grant # H133E030035.
Randy Bernard
CATEA
Georgia Institute of Technology
490 10 th Street
Atlanta , GA 30318
404.385.4691