Propel Manual or Electric Wheelchair Over Even Surfaces

1. Move Trunk While Sitting in a Wheelchair - Initially, the patient moves laterally from a midline sitting position, in a slight lean, to his/her balance point and practices returning to upright using head and scapula motions. After increasing the arcs of motion, the patient then practices throwing the head and shoulders forcefully in one direction, and then in the other direction, to move the trunk past the balancing point to the side opposite the throw.

2. Place Palms Against and Push/Pull Handrims - The patient:
   • Learns the proprioceptive and tactile sensations from the hands and arms when the therapist passively places the palms against the handrims, and then progresses to placing the palms independently (if training is required)
   • Learns to compensate for nonfunctional finger flexors by learning to press the palms inward against the rims of the wheels and push forward
   • Learns to compensate for inadequate upper extremity strength to propel the chair forward, in one or more of the following ways:
     • The therapist places the chair's casters in a trailing position, and, if necessary, pushes the chair slightly until the patient achieves the needed strength
     • The therapist wraps the chair's handrims with rubber tubing, which provides small handholds and makes pushing easier. As the tubing deteriorates, the patient's strength may have increased so new tubing is not necessary
     • The therapist places pegged handrims on the chair to make pushing even easier. However, the physical and skill prerequisites needed for pegged handrims are different from those needed for standard handrims, making the transition to the latter more difficult if pegged, rather than wrapped, handrims are used
   • Learns to compensate for nonfunctioning finger flexors and lack of active grasp, by learning to press the palms inward against the rims and pull backward
   • Learns to compensate for inadequate upper extremity strength to propel the chair backward, by the therapist positioning the casters of the chair anteriorly, and pushing, if necessary at first

3. With Palms on Tires, Propel Wheelchair Backward - After placing the arms behind the chair's push handles and the palms on the tires, the patient extends the elbows, depresses the scapulae, and pushes the tires backward, with the therapist moving the patient through the motions passively, and/or positioning the casters anteriorly, positioning the handrims symmetrically on both sides of the chair, and giving the chair a push, if necessary. The patient may be able to use scapular depression alone.

4. With Palms or Forearms Against Handrim Projections, Pull Projections -After placing the palms or forearms against the posterior aspect of the handrim projections, the patient learns to pull the projections:
   • Forward - by the therapist moving the patient through the motions passively, and/or positioning the casters in a trailing position and the handrims symmetrically on both sides of the chair, and giving the chair a push, if necessary at first
   • Backward - by the therapist moving the patient through the motions passively, and/or positioning the casters anteriorly and the handrims symmetrically on both sides of the chair, and giving the chair a push, if necessary at first

5. Propel Manual Wheelchair Over Even Surfaces - Patients who need to learn this skill must practice pushing either standard or pegged handrims at every opportunity - on the way to meals, therapy, and during free time. Propulsion may be very slow at first, and then gradually increase in strength and speed, until the patient can push with the hands well back on the handrims and use long, efficient strokes to push and allow the chair to glide between strokes

6. Place Arm or Hand on, or Use Chin or Tongue Motions, to Move Joystick -
   • To place arm on joystick, the patient with inadequate strength in the deltoids and biceps to move against gravity using elbow and shoulder flexion, uses a series of motions. If:
     • Arm initially hangs down outside the armrest - the patient elevates the scapula to lift the arm, partially abducts and internally rotates the shoulder, places the elbow in a gravity-reduced position, and flexes the elbow to place hand on joystick. At first, the patient's arm may be suspended in a sling or supported by a skateboard placed on a board, to enable practice moving through gravity-eliminated arcs and progress to a slight then steeper slope. The patient practices moving the hand onto the joystick from a position, just lateral to the stick at first, and then progresses to positions that are more lateral and inferior.
     • Arm is initially positioned in the lap - the patient moves the arm to the outside of the armrest (by using scapular elevation and retraction, shoulder abduction and external rotation, and elbow flexion), and then follows the steps above
   • With hand on the joystick (achieved independently or dependently) and the wheelchair motor disconnected, patients with weaker proximal musculature and poor scapular and shoulder control practice pushing the stick in various directions. At first, and until the patient can move the joystick:
     • The patient's arm may be suspended in a sling or supported by a skateboard placed on a board
       • Forward and backward motion is achieved by using scapular abduction and adduction respectively
       • Lateral motion is achieved by using glenohumeral horizontal adduction and abduction
       • Diagonal motion is achieved by combining glenohumeral and scapular motions, or,
     • In addition to suspendeing the patient's arm in a sling, the therapist can splint the elbow and wrist, and/or strap the hand to the joystick
   • Using chin or tongue motions and with the motor disconnected, the patient practices moving the joystick up, down, laterally, and diagonally using chin control and neck and jaw motions, and practices pushing the stick using mouth control, if practice is required

7. Signal and Propel Electric Wheelchair Over Even Surfaces - After learning to signal the chair (by sipping and puffing in a pattern or by pushing the joystick using the hand or chin or mouth control) and with the wheelchair motor connected, the patient begins training at low speed, in a large area free of obstacles, and with a therapist present to override controls when needed, by learning first to control the chair (start, stop, maneuver is different directions) and then propelling over larger areas and maneuvering around obstacles.