Physical Exam Considerations for People who use Wheelchairs

In addition to the regular checks of a physical exam, examinations for patients who use wheelchairs should be adapted to address their specific needs. This ensures that the patient's mobility, injury risk, and quality of life are not threatened by extended periods of sitting, potentially without proper weight shifts. This requires healthcare providers that understand these requirements, easily accessible medical equipment, and staff who are adequately trained to operate the equipment. For example, people with mobility disabilities are at risk of developing pressure sores.

Prolonged sitting on the wheelchair causes increased temperature and moisture in areas of contact with the wheelchair surface. Such injuries look like localized areas of skin and soft tissue damage and are common over the occiput, sacrum, and ischial tuberosities of the patient. If the patient uses a manual wheelchair, bony prominences like elbows and greater trochanters may show abrasions, erythema, and ulcerations.

The correct fit in the wheelchair is also important for the patient's comfort, to improve mobility and overall health. While checking for a wheelchair fit, the seat width, depth, and height must be determined to ensure that the patient can sit comfortably in it. Similarly, the armrests, footrest, and backrest height must be decided according to the user's needs. For example, patients with difficulty in sitting upright need a higher backrest. In comparison, a backrest with free movement of the shoulders is required for patients who push the wheelchair themselves.

Additionally, a patient's weight can be an important indicator of the patient's health. A wheelchair scale must be used to weigh patients in a wheelchair who are unable to stand on their own.   This measurement must also be taken into consideration because wheelchairs are meant to accommodate a certain weight, which can affect comfort, fit, and overall patient wellbeing.

A new wheelchair or seating adjustment may be required when the patient's posture seems to lead to deformities, pain, or skin abrasions. For example, pain in the shoulder is indicative of a wrong posture while using a manual wheelchair.

Overall, most details related to the medical care for people who use wheelchairs are no different than the care provided to every other person.

This video aims to help clinical practitioners who may encounter but are not familiar with caring for patients who use wheelchairs. Although people with mobility impairments may use manual and power wheelchairs, we primarily highlight how to care for those who use manual wheelchairs, irrespective of their underlying diagnoses.

In this video, we will demonstrate how to measure weight and what specific clinical considerations to take into account while performing a physical examination on a patient who uses a wheelchair.

A clinic with accessible medical equipment greatly improves the quality of care for patients with mobility disabilities. Staffers responsible for operating the accessible medical equipment will need initial training and an annual review of the content to ensure appropriate use and storage.

Documenting the individual's weight is an important part of each medical encounter, and this can be a challenge for wheelchair users. This can be completed with an accessible scale that can accommodate a wheelchair.

To perform this data collection, first follow standard office protocols to obtain accurate weight measurements, such as having the patient remove their shoes and empty their pockets. If medical devices or durable medical equipment, such as feeding tubes or orthopedic braces, cannot be removed, make a note of this so that consistent procedures can be used for that patient in future measurements.

Now, turn on the scale. While remaining in the wheelchair, the patient should wheel onto the platform of the accessible scale, and then lock the wheels of the chair for safety purposes. The total weight of the patient and their equipment will be displayed on the scale, and this should be noted down.

Next, the weight of the wheelchair can be determined by weighing the chair without the patient in it. This step does not need to be repeated at every visit if the weight of the wheelchair is saved within the patient's record. If this is not possible for whatever reason, then the medical staffer should refer to the manufacturer's instructions for an estimated chair weight.

To calculate the patient's weight, subtract the weight of the wheelchair from the total weight of the patient plus the wheelchair. Finally, enter this information into the patient's record.

In addition to the area of focus for the clinical evaluation, the examiner may check wheelchair users for some additional health issues, such as pressure sores, which very commonly affect this population of patients irrespective of their disabling condition.

To begin, ask the patient if they perform regular skin checks at home. If yes, ask them what they have noticed. If they answer no, encourage them to do so. Next, inspect the skin over the occiput, sacrum, and ischial tuberosities of the patient. Pressure sores in these regions are more common in those who use wheelchairs due to increased sitting time. These sores can decrease quality of life, increase morbidity and mortality rates, and raise health care costs.

Then, inspect the elbows, greater trochanters, and any other bony prominences that are in direct contact with the manual wheelchair. Look for erythema, abrasions, and ulcerations in these areas also.  Additionally, ask the patient whether they have noticed any pressure sores on their sacrum or ischial area. Take time to remind them about the importance of performing regular skin checks of the sacral and ischial areas using portable mirrors to assess skin changes, as well as regular preventative pressure relief breaks if seated for two or more consecutive hours.

The clinician should look for several general indicators of wheelchair fit and wheelchair condition while observing the patient seated at rest and while starting to propel their chair. Wheelchair fit can alter for many reasons during a person's life due to changes in body habitus, posture, muscle tone, and more.

First, the body should be centered, not leaning to one side or another. Next, the feet should make full contact with the footplates. Assuming good trunk control, the lower angle of the scapulae should be at the upper edge of the backrest. Also, check that the hips and pelvis are pushed all the way back to the back of the seat. After that, ensure the head, neck, and shoulders are in a comfortable neutral position.

Now, if the patient uses a manual wheelchair, ask the patient to contact the push-rims and then make observations for the ideal seat height and axle position. For most conditions, where there is full and balanced upper body neuromuscular function, the angle between the upper arm and forearm should be between 100° - 120° when the hand is resting on the top center of the push rim. However, the ideal fit can change based on diagnosis. The crease of the knees should extend just beyond the front of the seat, and the knees and thighs should be level and even.

If any positioning red flags are picked up during the examination, or if the patient reports feeling a mismatch between them and their chair, referrals should be made to a multi-disciplinary wheelchair seating and positioning group so that the wheelchair's condition and fit can be optimized if and as needed. Without such optimizations, the patient's mobility, injury risk, and quality of life can be threatened.

Next, ask the patient if they have experienced recent or remote upper extremity pain on either side. Be sure to ask about general musculoskeletal pain, shoulder pain, and propulsion-related pain. Assuming good trunk control, carry out a quick shoulder screen by asking the patient to actively forward flex, and abduct each shoulder, as well as perform active internal and external rotation. Look for any asymmetries or pain-limited movement dysfunction.

If the patient has any other persistent pain, assess this for an etiology. If any upper extremity red flags, such as bruising, skin injury, tenderness to palpation, joint pain, or propulsion-related pain, are picked up during the examination, make appropriate referrals to specialty non-surgical orthopedic and surgical orthopedic specialists.

Upper extremity function, especially shoulder, is vital to manual wheelchair propulsion and other activities of daily living in this population. If shoulder or propulsion-related pain goes unaddressed or inadequately addressed, the patient's mobility, injury risk, and quality of life can be threatened.

After that, ask the patient if they have any other areas of discomfort or concern based on body mechanics or wheelchair fit. A more detailed examination may be indicated based on the patient's concerns or history of pain or injury to the upper or lower extremities.