The Benefits of Power Wheelchair Tilt, Recline and Leg Rests, Power Wheelchair Standing Systems, and Standing Frames for Power Wheelchair Users

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The Benefits of Power Wheelchair Tilt, Recline and Leg Rests, Power Wheelchair Standing Systems, and Standing Frames for Power Wheelchair Users

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accurate & up-to-date snapshot of these matters

Research question:

What are the benefits for wheelchair users of a wheelchair with powered recline, elevating leg rests, seat elevate and power standing compared to use of: i. ‘standard’* wheelchair alone ii. ‘standard’ wheelchair and standing frame iii. wheelchair with powered recline, elevating leg rests, seat elevate and power standing *for the purposes of this research, ‘standard’ means ‘without powered recline, elevating leg rests, seat elevate and power standing’

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1. Contents

The Benefits of Power Wheelchair Tilt, Recline and Leg Rests, Power Wheelchair Standing Systems, and Standing Frames for Power Wheelchair Users ……………………………………………. 1

1. Contents ……………………………………………………………………………………………………….. 2

2. Summary ………………………………………………………………………………………………………. 2

3. Power Wheelchairs …………………………………………………………………………………………. 3

3.1 Tilt, Recline and Elevating Leg Rests ……………………………………………………………… 3

3.2 Standing Systems ………………………………………………………………………………………… 4

3.3 Standing Frames …………………………………………………………………………………………. 5

4. Reasonable and Necessary ……………………………………………………………………………… 6

4.1 Spinal Cord Injury ………………………………………………………………………………………… 6

4.2 Duchenne Muscular Dystrophy ………………………………………………………………………. 7

4.3 Multiple Sclerosis …………………………………………………………………………………………. 8

4.4 Cerebral Palsy …………………………………………………………………………………………….. 8

5. Literature Review ………………………………………………………………………………………….. 10

6. References ………………………………………………………………………………………………….. 29

7. Version control ……………………………………………………………………………………………… 32

8. Summary

This literature review compares the benefits of standard power wheelchairs to power wheelchairs with recline, tilt and elevating leg rests, power wheelchair standing systems, and standing frames for power wheelchair users. Power wheelchair tilt, recline and elevating leg rest systems offer benefits such as improved posture management, reduced risk of pressure ulcers, and increased independence with activities of daily living. Standing systems and standing frames can support power wheelchair users to stand independently, which offers benefits such as improved independence and community engagement, reduced pressure off the buttocks and back, and improved bowel and bladder function. Which support is reasonable and necessary for a participant will depend on a number of factors including their disability type, their ability to stand or change positions independently, and their level of informal and community supports.

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3. Power Wheelchairs

Power wheelchairs can include tilt systems, recline systems, and elevating leg rests [1].

 Tilt systems adjust the seat angle in relation to the ground while maintaining the seat backrest and leg rest angles.  Recline systems change the angle of the seat backrest  Elevating leg rests allow the user to adjust the angle of the leg rest and/or foot rest. Some are articulating, enabling the user to extend the knee.

Some power wheelchairs also include a standing system, enabling the user to reach a standing position without transferring out of their wheelchair [2]. Some wheelchair users may use a standing frame in order to stand rather than a power wheelchair standing system if they are able to transfer from their wheelchair.

3.1 Tilt, Recline and Elevating Leg Rests

Tilt, recline and elevating leg rests may be prescribed to address issues related to postural alignment, function, pressure management, spasticity, oedema, and biomechanical issues [1]. Power wheelchair users with a tilt/recline system frequently use the tilt/recline feature, with one study finding that users spent 64% of their time each day in a tilted position, and used the tilt function on average 19 times per day and backrest recline 12 times a day [3].

Wheelchair tilt and recline mechanisms relieve pressure on the buttocks, redistributing body weight to other surfaces such as the back or feet [4,5]. Redistributing body weight is particularly important for people with Spinal Cord Injuries (SCI), who are at high risk of pressure ulcers due to limited mobility and sensation [6]. Redistribution of body weight away from the buttocks may reduce the risk of power wheelchair users with SCI developing pressure ulcers [4,5]. This is further supported by evidence that tilt and recline can improve muscle and skin perfusion around the ischial tuberosities (part of the lower pelvis) in people with SCI, and therefore possibly reduce the risk of pressure ulcers [7,8]. Feet elevation using elevating leg rests when used with back rest recline can also reduce pressure on the buttocks [9]. Although there is experimental evidence that wheelchair tilt and recline systems can reduce pressure on the buttocks and improve muscle and skin perfusion around the ischial tuberosities, there is a lack of longitudinal studies comparing pressure ulcer risk in power wheelchair users with and without tilt/recline function. Pressure on the buttocks can also be managed using wheelchair cushions for people with SCI [10,11]. Studies in elderly wheelchair users indicate that wheelchair seat cushions reduce the incidence rate of pressure ulcers [12,13], however this has not been investigated in people with SCI or other disabilities.

Tilt and recline systems are also used to manage pain [1]. Many power wheelchair users experience pain due to long-term sitting [1], with one study finding that the majority of power wheelchair users reporting that their power wheelchair impacts their pain levels [14]. A survey of power wheelchair users with wheelchairs that had tilt/recline functions revealed that at least 70% used the tilt/recline function to reduce pain [15]. These results have been supported by a

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further survey of power wheelchair users and prescribers which found that one of the primary reasons people used their wheelchair tilt/recline mechanisms was to manage pain and discomfort [16]. Furthermore, in a survey of power wheelchair users with Multiple Sclerosis (MS), those who had a wheelchair with a tilt/recline function were more likely to report that their wheelchairs are comfortable than power wheelchair users without tilt/recline functions [17], and people who use power seat functions more frequently experience less wheelchair discomfort [18].

Tilt functions can also increase the wheelchair user’s functional capacity. One study found anterior tilt can significantly increase a person’s reach, which power wheelchair users noted was meaningful for them to be able to perform some daily activities independently [19]. This study also found that anterior tilt increased safety and reduced the need for assistance during meal preparation.

Some power wheelchair users experience fatigue due to their disability. Tilt/recline systems can enable power wheelchair users who experience frequent fatigue to use their wheelchair to rest comfortably without having to be transferred to a chair or bed [17]. Some standard power wheelchair users who experience fatigue reported that they spent prolonged periods in bed or in chair rather than using their wheelchair, reducing their mobility [17].

3.2 Standing Systems

Standing offers many benefits for wheelchair users such as reducing pressure off the back and buttocks [4], improving independence and social participation [20-23], and possibly improving bowel and bladder function [24,25]. Power wheelchair standing systems can enable power wheelchair users who are unable to transfer to a standing frame to obtain a standing position [2]. Power wheelchair standing systems also enable the user to mobilise while in a standing position [2].

For adolescents with Duchenne Muscular Dystrophy (DMD), power wheelchair standing devices are important for participating in school activities such as sport, social and leisure activities, and for activities of daily living such as toileting independently [20,23]. There is evidence that power wheelchair standing devices can improve the mental health of adolescents with DMD, likely due to the standing system giving increased independence and ability to be more involved in school [21]. Clinicians internationally agree that power wheelchair standing devices are a mobility option which offers independence to children with DMD, and should be ideally trialled when the child is predicted to lose the ability to walk in the next one to two years [26]. For adolescents at the later stages of the progression of DMD, pain can be a barrier for using their wheelchair to stand, with some adolescents ceasing use of the standing system as their DMD progresses to the late stages [20].

Increased independence has also been found in a study exploring the use of power wheelchair standing devices in children with other disabilities including cerebral palsy, spinal muscular atrophy, spina bifida and SCI [22]. Children who use power wheelchair standing devices, their parents, and treating health care professionals frequently mentioned when interviewed that the

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standing system enabled the child to stand when they needed to independently, increasing independence with tasks such as hand washing and reaching for objects [22]. This study also noted the mental health benefits of power wheelchair standing systems, with many parents reporting that their child had increased confidence and self-esteem after being prescribed with a power wheelchair standing device.

Power wheelchair standing systems can also be beneficial for people with SCI. People with SCI self-report that prolonged standing results in improvements to respiration, circulation, bowel and bladder function, sleep, and reduces pain and fatigue [27,28]. However, this has not been investigated experimentally. There is also limited evidence that standing for prolonged periods may also prevent loss of bone density and osteoporosis, which are common complications in people with SCI [29]. Wheelchair standing systems can also relieve pressure on the buttocks and back for people with SCI by transferring weight to the feet, possibly reducing the risk of pressure ulcers [4]. Standing provides a more functional position than tilt/recline for the relief of pressure ulcers, enabling power wheelchair users to continue daily activities whilst relieving pressure off the buttocks and back [4]. Although there are many benefits to standing for people with SCI, the cost of equipment and assistance to enable standing is a common barrier to standing more often [27].

3.3 Standing Frames

Standing frames are an assistive technology which support a person to stand. Standing frames may be used by wheelchair users to provide an alternative position to sitting, which has benefits such as reduced pressure off the buttocks and back, improved independence and social participation, and improved bowel and bladder function [2].

For children with Cerebral Palsy (CP), standing frames provide an opportunity to change position, and improve the child’s participation in school and social activities [25]. When clinicians who prescribe standing frames for children with CP and parents who have children with CP who have used standing frames were surveyed, they also reported improvements in bladder and bowel function. However, the only study specifically investigating the effect of standing frames on bowel function in children with CP was a case study of a single child [24], which did find that the standing frame improved bowel function. Although clinicians and parents viewed standing frames as having a positive impact overall on the independence and participation of children with CP [25], when young people with CP were interviewed some mentioned that the standing frame reduced their independence and social participation [30]. This was because the standing frame was static, whereas being seated in their wheelchair offers mobility. Additionally, for some young people standing using a frame requires significant concentration and effort, making engaging and participating in activities while using their standing frame challenging. For a standing frame to be beneficial in an educational setting, a multidisciplinary approach is required between health and educational professionals [31, 32]. There is also evidence that daily standing using standing frames in young children with CP

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have improved hip joint alignment compared to children with CP who did not regularly stand, possibly reducing risk of hip problems later in life [33].

For people with SCI, standing frames can relieve pressure off the buttocks and improve circulation, bowel and bladder function, and reduce pain [27]. Some individuals with SCI will be able to transfer to a standing frame independently, whereas some will require assistance to transfer. Standing frames have also been shown to be beneficial for people with progressive Multiple Sclerosis (MS), with regular use of standing frames improving motor function, continence, spasms and quality of life [34, 35].

4. Reasonable and Necessary

Power wheelchairs, power wheelchair tilt/recline systems, power wheelchair standing systems and power wheelchairs used with standing frames all offer increased mobility and independence for people with a range of different disabilities. Generally, which support(s) from these are reasonable and necessary for a participant depends on a number of factors including their disability type, their ability to stand independently, and level of informal and community supports.

In this section we discuss further considerations which should be made when determining which support(s) meet reasonable and necessary criteria for the disability types more commonly investigated in the scientific literature.

4.1 Spinal Cord Injury

For people with SCI, each individual’s personal circumstances and function must be taken into account when making a reasonable and necessary decision. Standing is important for people with SCI as it reduces the risk of pressure ulcers [4,5], and may improve circulation, bladder function, and help to maintain bone density [27, 29]. Some individuals will be able to independently transfer from their wheelchair to a standing frame, whereas others will require assistance. If a person requires assistance to transfer from their wheelchair to a standing frame this may limit their independence, particularly if they have limited informal supports. For these people, a power wheelchair with a standing system may be more suitable. For individuals with SCI who cannot stand for prolonged periods due to their need for respiratory assistance [27], a power wheelchair with a tilt/recline function may be most suitable to relieve pressure off the buttocks and prevent pressure ulcers [5]. Additionally, many people with SCI experience orthostatic hypotension when standing, with 25% of people with SCI saying that they avoid standing devices such as standing frames and standing wheelchairs due to orthostatic hypotension [36]. For these people, a wheelchair with a tilt/recline function may be more suitable to relieve pressure of the buttocks to prevent pressure sores, rather than a standing device. It is also important to note that wheelchair seat cushions which are a lower cost support can also reduce pressure on the buttocks for people with SCI [10], and has been shown to reduce the incidence of pressure ulcers in elderly patients without SCI [12,13]. However, wheelchair seat cushions do not offer other benefits such as better bladder function,

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improved pain management, and increased independence which wheelchair tilt/recline, standing systems and standing frames offer [2].

Due to the clear benefits of tilt/recline systems, standing frames or standing systems in preventing pressure ulcers, and the increased risk of pressure ulcers for people with SCI [6], we suggest that ‘standard’ power wheelchairs alone may not meet section 34(d) of the NDIS Act 2013 unless the person is able to stand and change positions.

When considering whether a tilt/recline system, standing frame, or power wheelchair standing system meets reasonable and necessary support for a person with SCI, advisors should consider:

 the cost of each support

 whether the participant can independently transfer from their wheelchair to a standing frame. If not, what informal or community supports do they need to assist them to transfer to a standing frame? If the participant has no informal or community supports to assist with transfers, what is the cost of supports to transfer between the wheelchair and standing frame?

 whether the participant requires respiratory assistance which limits their ability to stand

 if the participant currently uses a standard power wheelchair, whether they experience symptoms such as pain, fatigue and poor bladder control which limits their community and economic participation

 whether the participant frequently experience orthostatic hypotension. If so, whether this prevents them from using a standing frame or standing system due to a fear of symptoms such as fainting or nausea.

4.2 Duchenne Muscular Dystrophy

For young people with DMD, power wheelchair standing systems provide increased independence and improved community involvement [20, 21, 23]. Power wheelchair standing systems provide greater independence than standing frames for young people with DMD, allowing them to participate in a greater range of school activities and enabling them to stand when they wish without the need of assistance to transfer to a standing frame [23]. We could not find research on the benefits of standing frames for people with DMD as there is minimal research on the use of assistive standing devices for people with DMD [37], with the limited research focusing on power wheelchair standing devices.

When considering if a standing system is reasonable and necessary for a participant with DMD, advisors should first consider if standing frames meet reasonable and necessary criteria as they are a lower-cost support. When considering if a standing frame is reasonable and necessary, advisors should consider:

 informal and community supports the participant has to transfer from a wheelchair to standing frame

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 whether informal supports will be able to continue to safely transfer the participant between a wheelchair and standing frame as they grow and become heavier

 if it safe for caregivers to transfer the participant from a wheelchair to standing frame in community settings.

When determining if a support is reasonable and necessary for a participant with DMD, the stage in the progression of DMD should also be considered. People with DMD are generally able to ambulate until age 11-12 [38], however clinicians recommend that standing systems should be ideally trialled when the child is predicted to lose the ability to walk in the next one to two years [26].

4.3 Multiple Sclerosis

Fatigue is a common symptom of MS [17], which could limit social and economic participation if the participant is required to frequently transfer to an armchair or bed to rest. Power wheelchair tilt/recline systems can enable a participant with MS to rest comfortably whilst outside of their home.

There is limited evidence that standing using a standing frame can improve strength and spasms for people with severe MS. We could not find any research on the use of power wheelchair standing systems for people with MS. As there is evidence that standing frames (a lower cost standing support) are beneficial for people at the late stages of MS [34, 35], it is unlikely that power wheelchair standing systems would meet section 34(c) of the NDIS Act 2013 unless other benefits are identified.

When considering if a power wheelchair with a tilt/recline system and/or standing frame is reasonable and necessary for a participant with MS, advisors should consider:

 the participant’s goals. For example, if the participant has goals related to increased economic or community participation, fatigue may be a barrier. In this case, a power wheelchair with a tilt/recline system may be necessary to manage fatigue outside of the participant’s home

 whether it safe to frequently transfer the participant from their wheelchair to an armchair or bed if they experience frequent fatigue

 the stage of progression of MS (severity).

4.4 Cerebral Palsy

The scientific literature focuses on the use of standing frames and power wheelchair standing systems in children with CP rather than adults. Standing frames will not meet reasonable and necessary criteria for all children with CP as there is substantial variation in the level and type of impairments for people with CP [39]. For children with CP who are unable to stand without the assistance of a standing frame, standing frames are likely to meet reasonable and necessary criteria as they enable the child to change position [25], improve hip joint alignment

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[33], and improve participation in school and the community [25, 30, 31] compared to using the wheelchair alone. Power wheelchair standing systems are unlikely to meet section 34(c) of the NDIS Act 2013 for children with CP as standing frames are a lower cost standing support, unless it is unsafe to transfer the child to a standing frame or it is extremely challenging for the child to balance using a standing frame.

Although there is a lack of research on the benefits of standing frames for adults with CP, it is likely that adults would experience some similar benefits to children such as increased participation in the community and improvements to bowel function [25]. Similarly to children, factors such as the participant’s level of impairment, ability to stand independently, and level of informal supports should be considered when making a reasonable and necessary decision.

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/ Evans, Kava, Rosen Clarke, Paleg, 2019 2009 2021-01-13 Author Date Vorster, Murphy, Cairns, Ryan, Siafarikas, Rowe, Parkinson, Gaynor. Mar Arva, Lange, Lieberman, Schmeler, Dicianno, Babinec, Sep V1.0

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/ Porter- 2003 2021-01-13 Author Date Stinson, Armstrong, Eakin. Mar V1.0

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/ Bray, Bundy. Young, McGuire, Bray, 2021-01-13 2021 Author Date Young, McKinnon, Burns, Jul Schofield, Evans, Paguinto, Carroll, Townsend, Kiefer, Sodhi, Bayley. V1.0

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of impact of spinal apparatus mobility use users injury: the Title Orthostatic hypotension following cord on standing Follow-up assessment standing device

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of of use for palsy of of study part people frame A palsy A as people’s standing cerebral young educational Title Understanding frames: qualitative young experiences using frames postural management cerebral Understanding frames: qualitative exploration standing for with in settings / Smith, McColl, Miller, Roberts. Crombie, Parr, Colver, Howel, 2018 2019 2021-01-13 Author Date Goodwin, Lecouturier, Crombie, Basu, Kolehmainen, Parr, McColl, Mar Goodwin, Lecouturier, Smith, Basu, Howel, Roberts, Cadwgan. May V1.0

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Title

/ 2021-01-13 Author Date V1.0

LiteratureFOI 24/25-0889Review

OFFICIAL For Internal Use Only

6. References

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7. Version control

Version Amended Brief Description of Change Status Date by

1.0 MBK223 Research paper comparing features of Approved 13/01/2022 standard and above standard wheelchairs.

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