Ramps and Uneven Terrain

1. Physical and Skill Prerequisites
   • Greater than normal strength in the anterior deltoids to ascend ramp and negotiate uneven terrain, and some anterior deltoid strength to descend
   • Some strength in the trapezius, middle and posterior deltoids, and in the biceps, brachialis, and/or brachioradialis. Also, some strength in infraspinatus, teres minor to ascend ramp and negotiate uneven terrain, and in pectoralis major, teres major, triceps, and hand musculature to descend ramp and negotiate uneven terrain
   • Normal range in scapular abduction and adduction, shoulder flexion, extension, and internal rotation, and elbow flexion and extension. Also, normal range in external shoulder rotation to ascend ramp and negotiate on uneven terrain, and in finger flexion to descend ramp in "wheelie" position and negotiate uneven terrain.
   • Ability to:
     • Propel wheelchair over even surfaces and up a slope to ascend ramp
     • Control wheelchair by applying friction to handrims while descending, steer to the right or left, and stop at will to descend ramp
     • Assume, maintain, glide forward, descend slope, turn, and propel backward in wheelie position to descend ramp and negotiate uneven terrain in wheelie
     • Ascend and descend slopes as steep as possible, but with a gentle grade of at least 1:12 for C5 lesion patients

2. Functional Skills
   • Ascending - The functional skills to propel forward in Manual Wheelchair Propulsion are modified to add a forward lean of the head and trunk (where possible), to avoid jerking the wheels abruptly (to prevent tipping the chair), and to use shorter strokes and move the hands rapidly between pushes (to avoid rolling backward between pushes)
   • Descending on 4 Wheels - The patient controls the chair, rather than propels it, when descending a ramp, by either:
     • Gripping the handrims loosely, but with enough resistance to slow and control the chair's descent, and allowing the handrims to slide through the hands, or,
     • Pressing the palms against the handrims, slightly in front of the hips, with the elbows slightly flexed and the shoulders internally rotated, if the patient lacks functioning finger flexors.
   • Descending in "Wheelie" Position - To avoid the chair coming to an abrupt stop (and possibly throwing the patient out of the chair) when the footplates reach the abrupt angle with the street or sidewalk, caused by a steep ramp, the patient can descend in a "wheelie" position. This is done by approaching the ramp and descending it on the rear wheels only, gripping the handrims loosely during the descent and allowing them to slide through the hands, to provide enough resistance to slow and control the chair during the descent.