Prescribing mobility devices needs careful consideration. First, you need to determine the right type of aid for a patient, and then consider the numerous manufacturers, models, and options.

It is important to keep in mind the multiple considerations that will ultimately dictate your selection of a particular mobility device to recommend to your patient. Considerations include your patient's strength, range of motion, orthopedic status, muscular tone, and cardiopulmonary status. Not only do patients have different demographics and diagnoses, they also present different lifestyles, tastes, and needs. Subsequently, they will require different types of ambulatory aids, the selection of which will be directed by these parameters as well as rehabilitation goals.

The patient's physical condition will play a strong factor in guiding the selection of mobility devices. Those without balance will need more stable devices, such as quad canes or walkers; those with better balance may use single-point canes or crutches. Patients without a lot of upper arm strength or endurance (eg, emphysema sufferers) might need rolling walkers—those with wheels on two of the legs—so they can maneuver the device more easily by pushing rather than lifting. Other patients may benefit from wheelchairs or standers.

SAFETY CONSIDERATIONS

Lifestyle and personal preferences must be carefully addressed to ensure the safety of any mobility device. When fitting for the proper wheelchair, considerations may include the potential for change in function or size; the need for an adjustable or modular frame; the method of propulsion—arms, legs, or both; positioning needs; and environmental needs that will dictate types of tires, casters, etc.

When it comes to safety in wheelchair use, maintaining skin integrity is a top priority. The prevention of pressure ulcers should be a paramount consideration for all new wheelchair users with diminished sensation, cognition, and mobility. Many clinicians are comfortable selecting cushions to prevent pressure ulcers via pressure measurements, periodic skin checks, or a combination of the two. But skin-integrity problems also can occur due to improper use of the cushion (such as poor inflation or improper orientation) or its continued use after cushion fatigue. For these reasons, wheelchair users and their caregivers must be properly trained on the proper use of cushions and taught to check if the cushion is in good repair.

Abrasions, bruises, and pinch points also can lead to skin-integrity problems. Abrasions or bruises can occur when mechanical-lift slings are left in the chair, when trunk or head supports are poorly padded or poorly aligned, or when abductor pads are poorly padded or misused as restraints. Postural restraints and supports, such as lap trays, belts, chest straps, or ankle straps—and their buckles and fasteners—can rub or bruise the skin when they are used to restrain movement, so they should be properly padded and sized to distribute the load on the skin. Unpadded railings on the leg rests or poorly padded armrests also can lead to skin problems. Pinch points from swing-away or removable hardware also should be monitored.

Certain seating systems are designed to correct or accommodate postural asymmetries or to support postural instability. If they are improperly designed or fitted to the user, postural supports can promote poor alignment, which can lead to orthopedic deformities such as subluxed joints (hips, shoulders), contractures, or obliquities. A proper seating evaluation, during which orthopedic limitations and instabilities are identified, is the most effective way to properly select postural supports. Too often, wheelchair users are asked to adopt a posture that their bodies cannot attain, and an orthopedic deformity occurs as a result. Examples include sitting a person with a kyphosis in a flat back that can further flex the trunk while encouraging hyperextension of the neck, or the spinal deformities that result from not supporting an unstable trunk.

Postural restraints must be considered in every safety assessment, as they can contribute to severe injury or death. Most clinicians have heard of asphyxiation injuries or deaths from restraints used in wheelchairs and beds. However, since postural restraints are a component of many seating systems, clinicians should understand several aspects of restraint safety. The majority of asphyxiation deaths due to restraints occur when the restraints are improperly applied.

Vest-type and lap-belt restraints are the most common restraints used in wheelchairs, and the vest-type restraint represents the highest risk. A loosely secured vest restraint that is attached to the backrest compresses the neck when the user slides down in the chair. Vest restraints might need to be loose to give the user some trunk mobility while preventing him or her from falling forward in the chair, so a tight vest restraint might hinder function.

A lap belt should always be used in conjunction with a vest restraint. A lap belt, securely fastened over the bony pelvis, will prevent the user from sliding forward in the seat, resulting in increased stability when seated and a reduced risk of injury from vest-type restraints. Belts work best when they are applied over the bony skeleton, because soft tissue deforms and deflects, thereby efficiently loosening the belt or changing the line of pull. But because belts work best over bone, they must be sized and padded properly to adequately distribute the load.

STANDARDS FOR STANDERS

Standers are often used to assist with functional positioning in both the classroom and home environments. Standing, using knee immobilizers for additional support when necessary, can help to lengthen the muscles most at risk for contracture in the lower extremities: the rectus femoris, the hamstring group, and the gastrocnemius. These are especially prone to abnormal shortening due to the fact that they cross two joints.

When muscle length is improved, it drastically changes a patient's ability to maximally participate in transfers and activities of daily living, such as self-dressing. How much easier is it to get one's pants on when the legs are straight? That level of self-empowerment goes a long way toward giving a patient some control and dignity when coping with his or her disease. Ameliorating muscle balance also helps to optimize gait efficiency, improve balance reactions, and maximize joint stability.

While there is no evidence-based research to support or deny the hypothesis, perhaps the slow, prolonged stretch also may help to lengthen the surrounding fascia. Deep fascial restrictions are often ignored during traditional range-of-motion programs, although their negative impact is hardly denied by most practitioners.

The thing about standers is that, by nature, they sound so static. While in the past this has been true, the proliferation of mobile standers has come to offer patients more independence. With these devices, the patient no longer has to worry about getting from one end of a room to another, nor endure the physiological and psychological trauma of another fall. Standers also have the additional benefit of allowing patients to attach a tray or basket so that the patient can carry objects without providing large challenges to their balance.

Recent advancements have seen the rise of power standers in the industry to assist patients with endurance concerns. For patients with neurodegenerative diseases, the advantage of energy conservation is immense. As many muscles of the shoulder girdle also double as accessory muscles of inspiration, having to propel a manual mobile stander may prove to be too high of a demand for the patient's short-term respiratory status. Giving the patient control of moving around both indoors and outdoors while at eye level can markedly improve his or her mental health and socialization.

Overall, today's mobility devices offer a variety of features, making it more possible to meet the needs of virtually every patient.

Susan Young is a contributing writer for Physical Therapy Products. For more information, contact .