The Right Stuff: Braces, Wheelchairs, and Environmental Modifications
Frank S. Pidcock, M.D.
Associate Director of Pediatric Rehabilitation
Kennedy Krieger Institute
707 North Broadway
Baltimore , Maryland 21205

Introduction

Concentric environments interfacing with the world are a good way to think about the challenges facing someone with transverse myelitis. There is the immediate environment that includes the things that come in contact with the individual (e.g., wheelchair, assistive devices for performing daily living tasks, car). The intermediate environment is the personal living space and would include one’s home. The community environment includes adapted public spaces like school and recreational areas. Lastly, the natural environment is the essentially unchanged spaces that provide a challenge, but are certainly not “off limits” (e.g., mountain climbing).

This article will review three areas that are essential components of the immediate and intermediate environments. They are lower extremity braces, wheelchairs, and living space modifications.

Ambulation

A major question and challenge for someone with acute transverse myelitis is whether he or she will be able to walk. If so, the questions of how far, how tiring will it be, and what kind of assistance will be needed are important.

Ambulation potential depends primarily on the level of spinal cord injury, but other factors may also play a part. These include energy expenditure related to level of injury, fitness, weight, spasticity, muscle contractures, and pain.

Categories of ambulation are defined as: 1. Community in which ambulation is used as the primary mode of mobility; 2. Household which includes walking within the home with relative independence and using a wheelchair as the primary mobility in the community; 3. Exercise which requires considerable assistance or energy expenditure (it is too great for ambulation to be functional); and 4. Nonambulatory which uses a wheelchair entirely.

The neurologic level of injury can be used to predict ambulation category. The level of T11 or below is associated with increased potential for walking. Individuals with complete involvement of the arms and legs do not become community ambulators. Regardless of the level of spinal cord injury, it is important to try for the highest level of weight bearing ambulation possible, because mobility provides the ability to overcome functional barriers. It increases self esteem and provides cardiopulmonary exercise. Requirements for ambulation training include the ability to strengthen muscles in the arms and legs, to control the pelvis and trunk, and to stabilize joints for balance.

What are orthotics?

Orthoses or braces are important pieces of equipment that enable mobility. They come in various sizes and shapes, but all share a similar purpose. This is to provide stability around a joint that is lacking due to muscle weakness or imbalance. The type of bracing needed will be different based on the level of spinal cord injury.

For example, someone with a T5 level injury can use a wheelchair and orthotic braces that include the hips, knees, ankles, and feet (HKAFO) for primary mobility. A walker or forearm crutches can be used with a “swing to” or “swing through” gait for shorter distance mobility. Braces that only include the knee, ankle, and foot (KAFO) are not recommended. An ankle foot orthosis (AFO) can be used for positioning, but not for aiding in ambulation. It does not provide enough support. A back brace or thoracolumbosacral orthosis (TLSO) is recommended for trunk support and postural alignment. 1

If the level is L5, which means there is control of the trunk and some control of the legs, the bracing options may be different. AFOs are used as the primary assist for mobility. A HKAFO is generally not needed, but on occasion may be required, if the muscles that extend the hips or separate the legs are weak. A KAFO may be necessary to control the position of the knee depending on the underlying strength and coordination. Excessive spinal curvature may occur so this should be checked periodically by the medical team. Walkers or crutches may not be needed. A TLSO is not required for ambulation. 1

Reasons for using braces are to help with standing, exercising, and walking. These activities are important to keep bones and muscles in the leg strong, as well as to relieve pressure on the sitting surfaces of the skin and stretch out tight muscle. Physicians and therapists evaluate a person’s abilities and will help to determine the optimal bracing system based on level of spinal cord injury, strength, endurance, and life style.

An excellent web site for understanding the different kinds of braces and their uses is http://spinaltimes.org. It contains a lot of useful information.

Wheelchair Basics

The three basic things to consider when ordering a wheelchair are safety, comfort, and mobility needs. A “wheeled” mobility system needs to accommodate orthopedic deformities, prevent skin ulcers, promote independence, and provide enough trunk stability to allow the arms and hands to function.

Components of a wheelchair include the frame, seat back and depth, brakes, arm and leg rests, type of cushion, lap belts, wheels, and inserts to provide stability. Each of these parts can be custom made and adjusted for each person.

Frames can be fixed or collapsible with the fixed ones being more sturdy, but not as convenient for transportation. The axle position can affect the stability of the wheelchair. Moving the axle forward and closer to the small wheels in front (casters) increases maneuverability, but decreases the stability of the wheelchair. The reverse is true, if the axle is moved backwards toward the large wheels. For some children, an expandable frame to accommodate for growth is appropriate.

A tilt in space frame maintains a 90 degree angle at the seat even when the chair is tilted backwards. This is to decrease the pressure on the sitting surface and is used for individuals who cannot shift their body weight independently. If the hips do not bend to 90 degrees, then the back has to be “opened” to a greater than 90 degree angle to accommodate this position. The best angle is one in which the pelvis is in a neutral or slightly forward tilt to achieve proper alignment of back muscles. An angle that is too much greater than 90 degrees may result in the need to use back extensor muscles to remain upright.

A guide for the right seat width is to measure across the widest point of the hips including braces and then adding two inches, one for each side. If the seat is too wide, spine curvature may occur from leaning to one side or the other. It also predisposes to unequal weight distribution from leaning to one side. A chair with a seat that is too wide is also harder to self propel, because it is harder to reach the hand rims.

The depth of the seat can be estimated by measuring from the rear of the buttock to behind the knees then subtract about two inches. This is a guideline and will vary depending on the size of the individual. If the seat is too short, then there may be excessive pressure on the sitting surfaces and the center of gravity will not be appropriately distributed causing the chair to be easier to tip over. An excessively long seat may put pressure on the back of the knees and decrease circulation to the legs.

Seat height should be measured from the bottom of the heel to the beginning of the thigh at the knee then add about two inches to compensate for clearance of the leg rests. The height of the seat will affect the ability for the wheelchair to fit under tables and desks, so this should be checked.

Cushions provide pressure relief over a stable seating base. They can be solid seats made from wood covered in vinyl, foam seats, air filled, or gel filled. Air filled ones have less balance and stability and are subject to leaks. Their main benefit is for pressure relief. The gel ones adjust to the movements of an individual, but they retain heat. Foam ones are cheap and light weight, but have a shorter life span and are harder to keep clean.

Brakes are usually of a push-pull variety to lock. Extension bars can be provided, if it is difficult to bend over to reach the lever. On sports type wheelchairs, the brakes are placed low so that they don’t interfere with propulsion.

Arm rests can be fixed or removable. The type will depend on the ability to transfer in and out of the chair. Foot rests can also be either fixed or detachable. The detachable variety can either swing away or be removed by lifting them off. Another type of foot rest is an elevating foot rest which may be used, if leg swelling is a problem. Footplates come in several sizes. Heel loops can be added to better keep the foot on the plate.

There are a variety of trunk supports or “guides,” lap belts, and trunk straps to choose from. Avoid “Y” straps or “H” straps connected to the lap belt. These configurations may cause choking.

The best approach to selecting a wheelchair is to form a partnership with your local seating clinic. This is definitely not a “one size” or “one age” fits all situation. Every family will have different needs. Hobbies, fitness, level of spinal cord involvement, and other health conditions will affect the choice of a chair and its components. Be aware that insurance policies have very specific rules guiding the purchase of durable medical equipment like wheelchairs.

Home Modifications

The following are some basic rules about home modifications for wheelchair accessibility. The official American standards are published by American National Standards Institute, 1430 Broadway, New York, NY 10018, (212) 642-4900. There are excellent resources now available on the internet. Although many are sites for companies that actually do the reconstruction, they usually have good information in them. Typing “wheelchair home access” into a search engine is a good way to find these sites. One good example is www.adaptiveaccess.com .

Stairs for ambulatory individuals should have a uniform height of 4 to 7 inches with a depth of 11 inches; handrails on both sides are recommended. Ramp slope must not exceed 1 foot in length for every one inch increase in height. Width of outdoor ramps should be between 36 to 48 inches. Outside entrances should include a landing with at least a level area of 5 feet by 5 feet. Doorway width of at least 32 inches is mandated, but a width of at least 36 inches is preferred. Doorknobs should be at a height of 36 inches from the floor. A minimum length of 4 ½ feet for clear approach to door is recommended; 10 inch kick plates should be attached to both sides of doors to decrease wheelchair inflicted damage. Hall width should be at least 3 feet with adequate turning space at the beginning and end of the hallway. At least 5 feet is needed for turning or maneuvering a wheelchair. Wood or tile floors are better for wheelchairs than carpets or rugs. Maximum window sill heights should be 2 feet 9 inches. Bedrooms should accommodate a full size double bed. A clear area of 4 feet on one side is needed for the wheel chair and 3 feet on the other side for making the bed.

Some interior designers have specialized in making home access easier. Cynthia Leibrock has written some very detailed books covering this area. She is the founder of “Easy Access to Health” which is a consulting group specializing in barrier free designs. 2

Good Things to Know

The following list of questions came from www.spinaltimes.org. I think they are very useful when dealing with vendors and issues affecting equipment.

Who is your vendor?

• Where are they located?
• How can you reach them in an emergency?
• Do they have an emergency number?
• Who is paying for your equipment?
• Are you responsible for part of this payment?
• Who will pay for repairs?
• How do you get repairs done?
• Can you get an update of the purchased item in the future? If so, how?
• Has the vendor made clear to you what they are required to provide in the way of repairs?

References:

1. Molnar GE, Alexander MA. Pediatric Rehabilitation, 3 rd edition, page 283. Hanley & Belfus, Philadelphia, PA, 1999.

2. Easy Access to Health, 1331 Green Mountain Drive, Livermore, CO 80536, (970) 219-0212.