Physical Exam Considerations for People who use Wheelchairs

1. Measuring The Weight of a Person who uses a Wheelchair  

1. A clinic with accessible medical equipment greatly improves the quality of care for patients with mobility disabilities. Staff responsible for operating the accessible medical equipment will need initial training and an annual review of the content to ensure appropriate use and storage of the equipment. 
2. Collecting the individual's weight is an important part of each medical encounter, and this can be a challenge for wheelchair users. This can be accomplished with an accessible scale that has a ramp to accommodate a wheelchair.
3. Direct the patient into the room that contains the accessible scale.
4. Follow standard office protocols used for all patients to obtain accurate weight measurements, such as removing shoes and emptying pockets. If medical devices or durable medical equipment cannot be removed (e.g., feeding tubes, orthopedic braces), make a note of this so that consistent procedures can be used for that patient for future measurements. 
5. Remove all items from wheelchair compartments and pockets.
6. While remaining seated in the wheelchair, the patient should move the wheelchair onto the platform of the accessible scale.
7. Note the weight recorded on the scale.
8. Note the weight of the wheelchair itself, by either referring to the manufacturer's instructions, or weighing the chair without the patient in it (e.g., when the patient is on the exam table later in the visit). This step does not need to be repeated at every visit if the weight of the wheelchair is saved within the patient's record.
9. Subtract the weight of the wheelchair from the total weight of the patient and the wheelchair to calculate the exact weight of the patient.

2. Areas of Unique Clinical Focus for People who use Wheelchairs

1. In addition to the area of focus for the clinical evaluation, healthcare providers should screen for some additional key areas that are important for the health of wheelchair users. This includes pressure sores, which very commonly affect wheelchair-bound patients, irrespective of their disabling condition.
2. Ask the patient if they perform regular skin checks at home. If yes, ask what they have noticed. If not, encourage them to do so.
3. Inspect the occiput, sacrum, ischial tuberosity, 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.
4. Pressure injuries of the sacral or ischial areas are more common in those who use wheelchairs for longer durations. These injuries can decrease quality of life, increase morbidity, and increase health care costs.
5. Inquire with the patient about any other areas of discomfort or concern based on body mechanics or wheelchair fit. A more detailed examination of these areas (including palpation and range of motion) may be indicated based on the patient's concerns, history of pain, or injury to the upper or lower extremities.
6. While examining the areas prone to skin breakdown, be sure to ask if the patient has noticed any pressure sores on their sacrum or ischial area. Also, remind them about the importance of performing regular skin checks of the sacral or ischial areas using portable mirrors, as well as to take regular preventative pressure relief breaks every two hours.
7. Wheelchair fit can change for many reasons during a person's life due to changes in spasticity, postural changes, or body habitus. The clinician should look for the following indicators of wheelchair fit while observing the patient seated at rest.
   1. The body should be centered, not leaning to one side or another.
   2. Feet should make full contact with the footplates.
   3. Assuming good trunk control, the lower angle of the scapulae should be at the upper edge of the backrest.
   4. The hips/pelvis should be pushed all the way back to the rear of the seat.
   5. The head, neck, and shoulders should be in a comfortable neutral position.
   6. One can tell the ideal seat height and axle position when the patient starts to propel their chair by contacting the push-rims. 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.
   7. The crease of the knees should extend just beyond the front of the seat, (assuming no lower extremity amputation) knees and thighs should be at level and even.
   8. Referrals should be made, when possible, to a multi-disciplinary wheelchair seating and positioning group, so that wheelchair fit can be optimized, if and as needed. Without adjustment/optimization, the patient's mobility, injury risk, and quality of life can be threatened.
8. Additionally, manual wheelchair users are at a higher risk of experiencing pain in their upper extremities.
9. Ask the patient if they have experienced recent or remote upper extremity pain on either side.
10. Assuming good trunk control, a quick shoulder screen includes asking the patient to actively forward and lateral flex each shoulder and perform active internal and external rotation to assess for any asymmetries or pain-limited movement dysfunction.
11. Persistent pain should be assessed for an etiology, as this can hinder the patient's mobility. Again, appropriate referrals should be made when needed to a specialty non-surgical orthopedic (i.e., physical medicine and rehabilitation, family medicine, sports medicine) and/or an orthopedic surgical specialist.