Have you struggled with getting an appropriately sized wheelchair for your patient? Do you know what things you should be measuring for your wheelchair seating to be effective? Do you just grab the first wheelchair you can find?

Let’s make wheelchair seating and fitting simple as possible.

Five keys to appropriate wheelchair seating.

1. Seat height is the distance from the floor to the seat of the wheelchair.
   It is determined by measuring the distance from the patient’s heel to their popliteal fold and adding two inches.
2. Seat depth is the distance from the front of the seat to the back of the seat.
   It is determined by measuring the distance from the patient’s posterior buttock to the popliteal fold and subtracting two inches.
3. Seat width is the distance from one side of the seat to the other.
   It is determined by measuring the widest part of the patient’s hips and adding two inches.
4. Back height is the distance from the top of the back portion of the seat to the bottom.
   It is determined by measuring the distance between the seat of the chair to the patient’s axilla, and subtracting four inches.
5. Armrest height is the distance between the seat and the top of the armrest.
   It is determined by measuring the distance between the seat of the chair and olecranon, and adding one inch.

(Fairchild, 136-137)

If a wheelchair is properly fitted, you should be able to:

• Fit two fingers between the edge of the seat and the patient’s popliteal fold.
• Fit your hands, placed vertically, between the patient’s thighs and the armrests.
• Fit four fingers between the top of the seat and the patient’s axilla.(Fairchild, 136-137)

The patient should obviously look comfortable, be sitting in an upright posture, and be able to operate the wheelchair without areas of excessive pressure or friction. A wheelchair that fits properly will both maximize mobility and ensure proper safety and support.

In addition to properly fitting the wheelchair, it is necessary to educate the patient and their family members or caregivers on proper pressure relief techniques and a pressure relief schedule.

• Anterior, posterior, and lateral weight shifts regularly
• Position changes every two hours (Giles, 405)
• Skin assessment of areas that are typically for pressure ulcers for wheelchair users

Five keys to appropriate patient positioning

Long term patient positioning must be considered for the prevention of pressure ulcers, as well as contractures.

1. Know common locations of pressure ulcers and contractures.
   These vary by what position the patient is typically in, but are commonly seen at bony prominences like occipital tuberosity, spine of the scapula, olecranons, sacrum, ischial tuberosities, greater trochanters, and posterior aspect of the calcaneus. Contractures into hip flexion, knee flexion, and plantar flexion are common and patient positioning should be assessed to ensure you are not contributing to their development. (Fairchild, 88)
   
2. Be able to position a patient into supine, prone, sidelying, hooklying, etc.
   Depending on the needs of the patient, they may need to be positioned one way or another, or a position may be contraindicated. Being able to position someone safely and effectively in a variety of ways will reduce the risk of pressure ulcers and contractures.
   
3. Educate your patient, their family, and their caregivers.
   Make sure they understand appropriate positioning and pressure relief techniques. You can’t supervise a patient all day. The patient and the people around them need to know what to do. Establishing trust and teaching effective education will ensure a patient’s safety when you are not there. Position changes are necessary to relieve pressure and prevent an area from getting irritated (Pressure ulcers: prevention and management, 30)
   
4. Watch out for patients with special considerations.
   Some patients may have special considerations you may need to take into account when positioning them. For example, patients with transfemoral amputations should not have their residual limb positioned in hip flexion, and patients with transtibial amputations should not have their residual limb positioned in knee flexion. Contractures into hip flexion and knee flexion make walking with a prosthetic much more difficult later on.  Patients with burns need to be splinted in positions of function and special care should be taken on areas that are very seriously burned. If a patient has other precautions, such as spinal precautions, sternal precautions, etc, you need to make sure you are adhering to them.
   
5. Skin check, skin check, skin check.
   It is easier to prevent an issue than to fix it afterwards. It is good idea to get into the habit of assessing a patient’s skin regularly in order to stop a problem before it even starts. If you see something going wrong, assess the situation, make changes, and reassess later.  

Final thoughts on wheelchair seating and fitting

As physical therapists, we are in the best position to help with this aspect of patient care. Sizing a wheelchair and positioning a patient is simple, easy, and can go a long way to prevent any complications during their care. Make sure you don’t forget these often overlooked aspects of our job!

References

• Fairchild, Sherly L, Pierson and Fairchild’s Principles & Techniques of Patient Care, 5th edition, 2013
• Giles, Scott, PT Exam, The Complete Study Guide, 2015
• Pressure Ulcers: Prevention and Management, NICE guidelines, 2014