Use of a pushrim-activated, power-assisted wheelchair enhanced mobility for an individual with cervical 5/6 tetraplegia

Neurology Report, Mar 2003 by Somers, Martha F, Wlodarczyk, Shelby

This patient's propulsion abilities with a manual wheelchair were consistent with the Consortium for Spinal Cord Medicine's17 description of typical functional outcomes for people with C5 or C6 tetraplegia. When using a PAPW however, this individual achieved a markedly higher level of independence in wheelchair propulsion. This higher level of independence is likely to make it more feasible for him to return to college and reintegrate into the life of his community. The patient expressed satisfaction with the PAPW because it provided him with enhanced mobility, required less effort to propel, felt more comfortable on his shoulders, and `looked better' than a power wheelchair.

An additional consideration in wheelchair selection is the equipment's impact on its user's future health. A number of studies have found that manual wheelchair propulsion can lead to upper extremity overuse injuries and pain, particularly in people with tetraplegia.5-16 These problems stem from mechanical stress on the upper extremities. A recent study comparing the metabolic costs of PAPW and manual wheelchair propulsion found that PAPW propulsion had a lower metabolic cost and required less mechanical work for the person propelling the wheelchair, giving evidence that PAPW propulsion was less stressful on the upper extremities.20 This finding is consistent with the experience of the patient described in this case report, who stated that he felt less stress in his shoulders when propelling a PAPW than when propelling a manual wheelchair. Thus, there is reason to suspect that propelling the PAPW might be less likely to lead to over-use injuries.

Although the PAPW described in this case provided enhanced mobility and possibly reduced the risk of overuse injury, it also had disadvantages when compared to a standard ultralight wheelchair. The power-assist drive wheels added 43 pounds to the total weight of the wheelchair (53 pounds minus the weight of the wheelchair's wheels). This weight made assisted negotiation of obstacles more difficult. The power-assist drive wheels also increased the wheelchair's width by 2 inches, which increased the minimal doorway width requirements for this individual. However, both of these disadvantageous characteristics (weight and width) were less pronounced than they would have been with a power wheelchair.

Another disadvantage of the PAPW is that it is new technology. Although research using a test dummy in a laboratory has shown PAPWs to be in compliance with wheelchair standards (set by the American National Standards Institute and the Rehabilitation Engineering and Assistive Technology Society of North America),20 PAPWs are relatively untested in the field. It remains to be seen how they will perform when individuals use them for community mobility over a period of years.

Perhaps the most problematic characteristic of a PAPW is its cost. At current prices, a PAPW system increases the total cost of a manual wheelchair by approximately $6,000. In comparison, a power wheelchair can cost as little as $3,000. The high cost of PAPWs is likely to increase the difficulty of obtaining funding for the equipment. On the other hand, a person who uses a PAPW does not require a second wheelchair; the power-assist wheels can be replaced with standard wheels, making the wheelchair usable when the power-assist wheels are being serviced. In contrast, a person who uses a power wheelchair should also have a manual wheelchair to use when the power wheelchair is being serviced, or when the person functions in environments that are inaccessible to power wheelchairs. Thus the cost differential between a PAPW and a power wheelchair/manual (back-up) wheelchair combination is less pronounced.