Wheelchair Guidelines (en for the Web)

8/3/2019 Wheelchair Guidelines (en for the Web)

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Guidelineson the provision of

Manual Wheelchairsin less resourced settings


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Guidelineson the provision of

Manual Wheelchairsin less resourced settings


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WHO Library Cataloguing-in-Publication Data

Guidelines on the provision o manual wheelchairs in less-resourced settings.

1.Wheelchairs - economics. 2.Wheelchairs - supply and distribution. 3.Wheelchairs - standards. 4.Disabled persons - rehabilitation. 5.Developing

countries. I.World Health Organization.

ISBN 978 92 4 154748 2 (NLM classication: WB 320)

World Health Organization 2008

All rights reserved. Publications o the World Health Organization can be obtained rom WHO Press, World Health Organization, 20 Avenue Appia,

1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; ax: +41 22 791 4857; e-mail: [email protected]). Requests or permission to reproduce

or translate WHO publications whether or sale or or noncommercial distribution should be addressed to WHO Press, at the above address

(ax: +41 22 791 4806; e-mail: [email protected]).

The designations employed and the presentation o the material in this publication do not imply the expression o any opinion whatsoever on the part

o the World Health Organization concerning the legal status o any country, territory, city or area or o its authorities, or concerning the delimitation

o its rontiers or boundaries. Dotted lines on maps represent approximate border lines or which there may not yet be ull agreement.

The mention o specic companies or o certain manuacturers products does not imply that they are endorsed or recommended by the World Health

Organization in preerence to others o a similar nature that are not mentioned. Errors and omissions excepted, the names o proprietary productsare distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to veriy the inormation contained in this publication. However, the

published material is being distributed without warranty o any kind, either expressed or implied. The responsibility or the interpretation and use o

the material lies with the reader. In no event shall the World Health Organization be liable or damages arising rom its use.

Contributors:

Editorial committee Geo Bardsley, Marc Krizack, Abdullah Munish, Kim Reisinger, Sarah Sheldon

Editors Johan Borg and Chapal Khasnabis

Authors William Armstrong, Johan Borg, Marc Krizack, Alida Lindsley, Kylie Mines, Jon Pearlman, Kim Reisinger,

Sarah Sheldon

Peer reviewers Jocelyn Campbell, Stean Constantinescu, Fiona Gall, K N Gopinath, Sepp Heim, Ral Hotchkiss, R Lee Kirby, Anna

Lindstrm, Matt McCambridge, Shona McDonald, Ray Mines, Alice Nganwa, Jamie Noon, Tone Oderud, Alana Ocer,

Valeria Rodriguez, Osten Savelin, Elsje Schefer, Harold Shangali, Edd Shaw, Gertrud Stehr Hott, Claude Tardi, Isabelle

Urseau, David Werner

Illustrator Jen McKinlay

Testimonial authors Elly Bernard, Anca Beudean, Tun Channareth, Fiona Gall, Matt McCambridge, Shona McDonald, Laura Morales, Keo

Sovann

Financial support US Agency or International Development

Partner organizations Centre or International Rehabilitation, Disabled Peoples International, International Society or Prosthetics and Orthotics,

The Motivation Charitable Trust (Motivation), Whirlwind Wheelchair International (Whirlwind) at San Francisco State

University

Design and layout was done by LIV Com Srl.


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Preface 7

Executive summary 9

About the guidelines 13

1. Introduction 191.1 Appropriate wheelchairs 21

1.2 Users o wheelchairs 21

1.3 Need or wheelchairs 21

1.4 Rights to wheelchairs 21

1.5 Benets o wheelchairs 23

1.6 Challenges or users 241.7 Wheelchair provision 25

1.8 Types o wheelchair 27

1.9 Stakeholders and their roles 30

1.9.1 Policy planners and implementers 30

1.9.2 Manuacturers and suppliers 31

1.9.3 Wheelchair services 31

1.9.4 Proessional groups 32

1.9.5 International nongovernmental organizations 32

1.9.6 Disabled peoples organizations 331.9.7 Users, amilies and caregivers 34

2. Design and production 372.1 Introduction 39

2.2 Wheelchair design 40

2.2.1 General considerations in wheelchair design 41

2.2.2 Introducing wheelchair design 43

2.2.3 The design process 43

2.3 Wheelchair production and supply 45

Table of conTenTs


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4 I g u I d e l I n e s o n t h e p r o v I s I o n o m a n u a l w h e e l c h a I r s I n l e s s r e s o u r c e d s e t t I n g s

2.4 Functional perormance 46

2.4.1 Wheelchair stability 46

2.4.2 Manoeuvrability 49

2.4.3 Pushing eciency 53

2.4.4 Other unctional perormance characteristics 54

2.4.5 Evaluating unctional perormance 56

2.5 Seating and postural support elements 56

2.5.1 Seat bases 58

2.5.2 Cushions 59

2.5.3 Backrests 60

2.5.4 Footrests 60

2.5.5 Armrests 61

2.5.6 Rear wheels 62

2.5.7 Evaluating seating and postural support elements 622.6 Strength, durability and saety 62

2.6.1 Requirements 63

2.6.2 Evaluating strength, durability and saety 65

2.7 User trials and ollow-up 65

3. Service delivery 693.1 Introduction 71

3.2 Wheelchair service delivery 763.2.1 Steps in service delivery 76

3.2.2 Understanding individual user needs 77

3.3 Good practice in wheelchair service delivery 78

3.3.1 Overall service 78

3.3.2 Reerrals and appointments 79

3.3.3 Assessment 80

3.3.4 Prescription 81

3.3.5 Funding and ordering 82

3.3.6 Product preparation 82

3.3.7 Fitting 83

3.3.8 Training o users, amilies and caregivers 84

3.3.9 Follow-up, maintenance and repair 85

3.4 Personnel in wheelchair service delivery 86

3.4.1 Manuacturers or suppliers 86

3.4.2 Reerral networks 87

3.4.3 Service personnel 87

3.5 Monitoring and evaluation 91

3.5.1 The need to measure perormance 91

3.5.2 Monitoring 91

3.5.3 Evaluation 93


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t a b l e o c o n t e n t s I 5

4. Training 974.1 Introduction 99

4.2 Training requirements 102

4.2.1 Reerral networks 102

4.2.2 Role o wheelchair service providers 103

4.2.3 Trainers 106

4.3 Course modules and contents 107

4.3.1 Course modules 107

4.3.2 Course contents 107

5. Policy and planning 1115.1 Introduction 113

5.2 Policy 113

5.2.1 Developing a policy 113

5.2.2 International policies 114

5.2.3 Specic wheelchair provision issues 116

5.3 Planning 118

5.4 Funding strategies 121

5.4.1 Costing 121

5.4.2 Sources o unding 121

5.5 Links with other sectors 123

5.5.1 Health services and community outreach campaigns 1235.5.2 Education 123

5.5.3 Livelihood 124

5.5.4 Social 124

5.5.5 Inrastructure 125

5.6 Inclusion and participation 126

Annex A 128

Training resources 128Other resources 129


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The wheelchair is one o the most commonly used assistive devices or enhancing personalmobility, which is a precondition or enjoying human rights and living in dignity and assists peoplewith disabilities to become more productive members o their communities. For many people, anappropriate, well-designed and well-tted wheelchair can be the rst step towards inclusion andparticipation in society.

The United Nations Standard Rules on the Equalization o Opportunities or Persons with Disabilities,the Convention on the Rights o Persons with Disabilities and World Health Assembly resolutionWHA58.23 all point to the importance o wheelchairs and other assistive devices or the developingworld, where ew o those who need wheelchairs have them, insucient production acilities exist,and all too oten wheelchairs are donated without the necessary related services.

When the need is not met, people with disabilities are isolated and do not have access to the sameopportunities as others within their own communities. Providing wheelchairs that are t or thepurpose not only enhances mobility but begins a process o opening up a world o education, workand social lie. The development o national policies and increased training opportunities in thedesign, production and supply o wheelchairs are essential next steps.

In the light o the realities o the developing world and the immediate need to develop unctioningsystems o wheelchair provision in less-resourced parts o the world, the World Health Organization(WHO), the US Agency or International Development, the International Society or Prosthetics

and Orthotics and Disabled Peoples International, in partnership with the Centre or InternationalRehabilitation, the Motivation Charitable Trust and Whirlwind Wheelchair International, havedeveloped this document to assist WHO Member States to create and develop a local wheelchairprovision system and thereby implement Articles 4, 20 and 26 o the Convention on the Rights oPersons with Disabilities. We extend our thanks to the US Agency or International DevelopmentsPatrick Leahy War Victims Fund or its support in producing these guidelines and assisting in theirimplementation.

Etienne Krug

Wod Hath Oaizatio

Lloyd Feinberg

US Ac oItatioa Dopmt

Dan Blocka

Itatioa Socit oPosthtics ad Othotics

Venus Ilagan

Disabd Pops Itatioa

Preface


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execuTive summary

These guidelines seek to promote personal mobility and enhance the quality o lie o wheelchairusers by assisting Member States in developing a system o wheelchair provision to support theimplementation o the Convention on the Rights o Persons with Disabilities (and specically Articles4, 20 and 26) and World Health Assembly resolution 58/23 o 25 May 2005.

The guidelines ocus on manual wheelchairs and the needs o long-term wheelchair users. Therecommendations are targeted at those involved in wheelchair services, ranging rom design andplanning, to providing or supplying wheelchairs and their maintenance.

The guidelines are divided into ve chapters:1. Introduction

2. Design and production3. Service delivery4. Training5. Policy and planning

1. Introduction

The introductory chapter describes the need or and benets o wheelchairs, types o wheelchairs,and systems or their provision. It also denes the requirements o adequate wheelchairs and

introduces the reader to the stakeholders and their roles.

A wheelchair must meet the users individual needs and environmental conditions, providepostural support, and be sae and durable. The wheelchair must be available and aordable andbe maintainable and sustainable in the country o use. This is not always easy, because wheelchairusers are a diverse group with dierent requirements and environmental and socioeconomicconditions.

The chapter argues that a wheelchair is more than an assistive device or many people withdisabilities; it is the means by which they can exercise their human rights and achieve inclusionand equal participation. A wheelchair provides mobility, ensures better health and quality o lie,and assists people with disabilities to live ull and active lives in their communities.

2. Design and production

Chapter 2 sets out guidelines on the design and selection o wheelchairs and how to produce andsupply them. The ocus here is to increase the quality and range o manual wheelchairs available inless-resourced settings. Health and saety, strength and durability, suitability or use, and eectiveproduction methods are the main design criteria. The design o a wheelchair determines itsunctional perormance in matters o stability, manoeuvrability, pushing and transerring eciency,

transport and reliability.


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1 0 I g u I d e l I n e s o n t h e p r o v I s I o n o m a n u a l w h e e l c h a I r s I n l e s s r e s o u r c e d s e t t I n g s

The guidelines address the design process, including the need or product testing, eld trials andlong-term ollow-up. The need to involve wheelchair users in the design process is highlighted, asthey are the most knowledgeable about their physical, environmental, social and cultural needs.Minimum guidelines and corresponding evaluation methods are given in the areas o unctional

perormance, seating and postural support elements, and strength and durability.

Governments are encouraged to develop and adopt national wheelchair standards to ensure areasonable level o quality, or instance by using the ISO 7176 series o wheelchair standards asa basis.

3. Service delivery

In this chapter, structural guidelines or systems that provide wheelchairs and that improve access

to wheelchairs are described. The need to provide wheelchairs together with other related servicesis shown to be essential. Careul planning and management o services and well-thought-outstrategies or wheelchair provision, user instruction and care are needed to acilitate the importantlink between the user and the wheelchair.

Guidelines in this chapter look at good practice at all stages o the service delivery process, romreerral to assessment and prescription, unding, ordering, product preparation, tting, usertraining and maintenance. The chapter includes a discussion o the roles o those involved inwheelchair service delivery, rom manuacturers and clinicians to technical and training personnel.Recommendations are made on monitoring, how to obtain eedback rom wheelchair users, andevaluating and analysing inormation on wheelchair service delivery.

4. Training

Chapter 4 looks at training requirements or those involved in the delivery o wheelchair services,with the aim o improving the level o skill o local people providing these services. Strategies areprovided or identiying trainers, linking to existing training programmes, developing modulartraining packages, and capacity building at the local level. The guidelines set out the trainingrequirements or those involved in reerral networks, managers o wheelchair services, and clinicaland technical personnel at basic and intermediate levels.

5. Policy and planning

Chapter 5 looks at the role o policy and policy-makers in wheelchair provision, with a specialocus on cost-eectiveness and sustainability. Suggestions are made about nancing options andways o linking wheelchair services to other sectors. A national policy on wheelchair provisionis recommended, with mechanisms or monitoring and evaluation, to ensure that users receivewheelchairs that meet minimum requirements or saety, strength and durability and are appropriateor their individual needs. Such a policy would look at need assessment, planning at the nationallevel, collaboration among service providers, the integration o wheelchair services with existingrehabilitation services, and the adoption o national standards, with the aim o empowering usersand their amilies and acilitating user participation in community lie.


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e x e c u t I v e s u m m a r y I 1 1

whchai a dic poidi whd mobiit ad sati suppot o a pso with dicut i wakio moi aoud

ss-soucdstti

a oaphica aa with imitd acia, huma ad iastuctua soucs to poidwhchais (a commo situatio i owad midd-icom coutis, but aso i ctai aaso hih-icom coutis)

maua whchai a whchai that is popd b th us o pushd b aoth pso

appopiat

whchai

a whchai that mts th us s ds ad iomta coditios; poids pop t

ad postua suppot; is sa ad duab; is aaiab i th cout; ad ca b obtaid admaitaid ad sics sustaid i th cout at th most coomica ad aodab pic

whchai us a pso who has dicut i waki o moi aoud ad uss a whchai o mobiit

psoa mobiit th abiit to mo i th ma ad at th tim o os ow choic

whchai poisio a oa tm o whchai dsi, poductio, supp ad sic di

whchai sic that pat o whchai poisio cocd with poidi uss with appopiat whchais

TFor the purpose o these guidelines, the ollowing terms are used in this document as dened

below.


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This part of the guidelines:

outlines the purpose and scope o the guidelines

presents the target readers

describes the structure o the guidelines

on provision of manual wheelchairsin less-resourced settings.

abouT The guidelines


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Wheelchairs changing lives

Box 1.

Tstimoia om a us i Coombia

Franber is an eight-year-old boy

who lives in Medelline, Colombia. He

cannot walk and his normal growth is

aected.

Franber used to spend his days

in bed while his mother worked

around the house. One day he

received a wheelchair through a

local organization. He can now move

around and best o all he can go

to school and enjoy breaks with his

classmates.


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Target readers

The intended readers include: government and nongovernmental policy-makers;

planners, managers, providers and users o wheelchair services; designers, testers, donors, purchasers and adapters o wheelchairs; planners and managers o wheelchair production; planners, developers and implementers o training programmes; developers o communication and advocacy materials; disabled peoples organizations; groups o users; and individual users and their amilies.

StructureThe guidelines are presented in ve chapters.1. The Introduction gives an overview o the need or wheelchairs, users o wheelchairs, types o

wheelchair, wheelchair provision and stakeholders.2. Design and production provides recommendations on how to design, evaluate and select

wheelchairs.3. Service deliverysuggests the tasks and structure o a system or providing wheelchair services.4. Training provides assistance in the design, development and implementation o training

opportunities or personnel involved in wheelchair provision.5. Policy and planning provides inormation to guide decisions on wheelchair provision.

Development process

Following consultations with a wide range o stakeholders, WHO ormed a small task orce todevelop the guidelines, contracting Johan Borg as editorial consultant and coordinator o the group.The main areas o the work were divided among various interested groups and their respectivepartners rom developing countries. Whirlwind Wheelchair International accepted responsibilityor the Design and production section, the Center or International Rehabilitation or Servicedelivery and the Motivation Charitable Trust or Training.

More than 25 wheelchair experts took part in the development o the guidelines. A complete drat oall the sections was prepared or a three-day discussion and review at WHO headquarters in Genevaon 2830 August 2006. Further revisions and external reviews took place during the two monthspreceding the International Society or Prosthetics and Orthotics (ISPO) Consensus Conerence onWheelchairs or Developing Countries, and a third drat was presented during the Conerence orurther eedback in Bangalore on 611 November 2006 (3).


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Wheelchairs to enhance quality of life

Box 1.1.

Tstimoia om a us i Ahaista

Zahida lives in Aghanistan,

in a tent in her brothers

yard. She became paraplegic

in 2001, but has had twochildren since then. She

was reerred to a hospital

outpatient physiotherapy

department in Jalalabad

and arrived pushed in

a wheelbarrow. The

physiotherapists worked

with the technicians o a

local wheelchair workshop to

provide Zahida with a three-

wheel wheelchair.

Without a wheelchair, Zahida

could do very little at home

without the help o her

husband and children. She

just lay on the bed. Her wheelchair has enabled her to successully look ater her children

in a very rough and hilly compound. Zahida says, My wheelchair it is like my eet I

wont go anywhere without it! With my wheelchair I can cook, make bread, visit the

neighbours. When we go to a amily wedding in the village I take it with me in the back o

the taxi. My older daughter and son help to push me up the steep places.


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make personal mobility possible. In 1993, the Standard Rules on the Equalization o Opportunitiesor Persons with Disabilities (3) expressed the same commitment, demanding that countriesensure the development, production, distribution and servicing o assistive devices or peoplewith disabilities in order to increase their independence and to realize their human rights.

These two important international declarations create rights to wheelchairs because it is universallyrecognized that an appropriate wheelchair is a precondition to enjoying equal opportunities andrights, and or securing inclusion and participation. Personal mobility is an essential requirementto participating in many areas o social lie, and wheelchairs are or many the best means oguaranteeing personal mobility.

Independent mobility makes it possible or people to study, work, participate in cultural lie andaccess health care. Without wheelchairs, people may be conned to their homes and unable to livea ull and inclusive lie. We know that eliminating world poverty is not possible unless the needso those with disabilities are taken into account. Without wheelchairs, these individuals are unable

to participate in those mainstream developmental initiatives, programmes and strategies that aretargeted to the poor, such as are embodied in the Millennium Development Goals (4), the PovertyReduction Strategies (5) and other national developmental initiatives.

It is a vicious circle: lacking personal mobility aids, people with disabilities cannot leave the povertytrap. They are more likely to develop secondary complications and become more disabled, andpoorer still. I they are children they will be unable to access the educational opportunities availableto them, and without an education they will be unable to nd employment when they grow upand will be driven even more deeply into poverty.

On the other hand, access to appropriate wheelchairs allows people with disabilities to work andparticipate in mainstream development initiatives that will reduce their poverty (see Fig.1.1.).Similarly, a wheelchair can enable a child to go to school, to gain an education and, when the timecomes, to nd a job (see Fig.1.2.).

The right to a wheelchair must be an essential component o all international endeavours to securethe human rights o people with disabilities.

Fi. 1.1. Us at wok Fi. 1.2. Us at schoo


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I n t r o d u c t I o n I 2 3

1

1.5 Benets of wheelchairs

Wheelchair provision is not only about the wheelchair, which is just a product (6). Rather, it isabout enabling people with disabilities to become mobile, remain healthy and participate ully in

community lie. A wheelchair is the catalyst to increased independence and social integration, butit is not an end in itsel(68) (see Fig.1.3.).

The benets o using an appropriate wheelchair include those outlined below.

Health and quality of life

In addition to providing mobility, an appropriate wheelchair is o benet to the physical healthand quality o lie o the user. Combined with adequate user training, an appropriate wheelchaircan serve to reduce common problems such as pressure sores, the progression o deormitiesor contractures, and other secondary conditions (9). A wheelchair with a proper cushion otenprevents premature death in people with spinal cord injuries and similar conditions and, in onesense, is a lie-saving device or these people. A wheelchair that is unctional, comortable andcan be propelled eciently can result in increased levels o activity. Independent mobility andincreased physical unction can reduce dependence on others. Other benets, such as improvedrespiration and digestion, increased head, trunk and upper extremity control and overall stability,can be achieved with proper postural support. Maintenance o health is an important actor inmeasuring quality o lie. These actors combined serve to increase access to opportunities or

education, employment and participation within the amily and the community.

Fi.1.3. Paticipatio i commuit i


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Economy

A wheelchair oten makes all the dierence between being a passive receiver and an activecontributor. Economic benets are realized when users are able to access opportunities or

education and employment. With a wheelchair, an individual can earn a living and contribute tothe amilys income and national revenue, whereas without a wheelchair that person may remainisolated and be a burden to the amily and the nation at large. Similarly, a wheelchair that is notdurable will be more expensive owing to the need or requent repairs, absence rom work andeventual replacement o the wheelchair. Providing wheelchairs is more cost-eective i they lastlonger (10). It is also more cost-eective i users are involved in selecting their devices and i theirlong-term needs are considered (11).

For society, the nancial benets associated with the provision o wheelchairs include reducedhealth care expenses, such as those or treating pressure sores and correcting deormities. A studyrom a developing country reported that in 1997, 75% o those with spinal cord injuries admitted tohospital died within 1824 months rom secondary complications arising rom their injuries. In thesame place, the incidence o pressure sores decreased by 71% and repetitive urinary tract inectionsell by 61% within two years as a result o improvements in health care training and appropriateequipment, including good wheelchairs with cushions (12).

1.6 Challenges for users

Users ace a range o challenges, which must be considered when developing approaches towheelchair provision.

Financial barriers

Some 80% o the people with disabilities in the world live in low-income countries. The majorityo them are poor and do not have access to basic services, including rehabilitation acilities (13).The International Labour Organization (ILO) reports that the unemployment rates o people withdisabilities reach an estimated 80% or more in many developing countries (14). Government undingor the provision o a wheelchair is rarely available, leaving the majority o users unable to pay ora wheelchair themselves.

Physical barriers

As many users are poor, they live in small houses or huts with inaccessible surroundings. Theyalso live where road systems are poor, there is a lack o pavements, and the climate and physicalterrain are oten extreme. In many contexts, public and private buildings are dicult to access ina wheelchair. These physical barriers place additional requirements on the strength and durabilityo wheelchairs. They also require that users exercise a high degree o skill i they are to be mobile.


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1

Access to rehabilitation services

In many developing countries, only 3% o people with disabilities who require rehabilitation serviceshave access to them (15). According to a report o the United Nations Special Rapporteur (16), 62

countries have no national rehabilitation services available to people with disabilities. This meansthat many wheelchair users are at risk o developing secondary complications and premature deaththat could be avoided with proper rehabilitation services. In many countries, wheelchair servicedelivery is not included in the national rehabilitation plan.

Education and information

Many users have diculty in accessing relevant inormation, such as on their own health conditions,prevention o secondary complications, available rehabilitation services and types o wheelchairavailable. For many, a wheelchair service may be their rst access to any orm o rehabilitationservice. This places even more emphasis on the importance o user education.

Choice

Users are rarely given the opportunity to choose the most appropriate wheelchair. Oten there isonly one type o wheelchair available (and oten in only one or two sizes), which may not be suitedto the users physical needs, or practical in terms o the users liestyle or home or work environment.According to the Convention on the Rights o Persons with Disabilities, States Parties shall takeeective measures to ensure personal mobility with the greatest possible independence or personswith disabilities by acilitating the personal mobility o persons with disabilities in the mannerand at the time o their choice, and at aordable cost (17).

1.7 Wheelchair provision

Wheelchair provision usually includes the design, production and supply o wheelchairs and deliveryo wheelchair services.

Fi. 1.4. Oiw o whchai poisio

pDeSIgn

pPrODUCTIOn

pSUPPly

pServICeDelIvery


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Materials and technology available

Wheelchair designs vary, depending on the materials and technology available or production andrepair, For example, wheelchair designers must take into account the strength and variability o

the available materials to avoid premature ailure. In the case o ailure, the wheelchair should beeasily repairable (20). See Chapter 2 or more inormation on this topic.

1.9 Stakeholders and their roles

1.9.1 Policy planners and implementers

Policy planners and implementers are directly involved in the planning, initiation and ongoingnancial, advisory and legislative support o wheelchair provision. The role o policy planners

includes the ollowing. Wheelchair provision policy is developed in consultation with other stakeholders, aiming at

eective measures to ensure personal mobility with the greatest possible independence orpeople with disabilities. This includes: facilitatingthepersonalmobility inthemannerandatthe timeoftheirchoiceandatan

aordable cost; accesstowheelchairs,includingmakingthemavailableatanaordablecost; providingtraininginmobilityskillstopeoplewithdisabilitiesandtorehabilitationpersonnel;

and encouragingentitiesthatproducewheelchairsandothermobilityaidswithinthecountry

Standards or wheelchair products, service delivery and training are adopted, promoted and

enorced. Measures are taken to ensure that wheelchair provision is equitable and accessible to all, including

women and children, the poorest and those in remote areas. Wheelchair services are developed as an integral part o health care structures and in coordination

with associated services, such as rehabilitation, prosthetic, orthotic and community-basedrehabilitation services.

Sustainable unding policies or wheelchair provision are developed. Wheelchair user groups and disabled peoples organizations are involved at every stage rom

planning to implementation.

According to United Nations Standard Rules and the Convention, it is the primarily responsibilityo countries to make wheelchairs available at an aordable cost. Ensuring the availability owheelchair services within a country does not necessarily mean the direct provision o servicesby the government. Nevertheless, the government can work closely with nongovernmental andinternational nongovernmental organizations, development agencies, user groups and the privatesector to develop national policies and a provision system. Furthermore, in developing the policyone needs to ensure that wheelchair services are cohesive and closely linked with national healthand rehabilitation strategies.


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1

ensuring their activities are part o a broader long-term strategy acknowledged and supportedby relevant authorities (e.g. the government);

building the capacities o disabled peoples organizations in accessing wheelchairs and developingpartnerships;

acilitating links between the various stakeholders users, wheelchair service providers andgovernments;

implementing wheelchair services by providing training expertise where none is available locally,and building capacities or both the technical and organizational aspects o wheelchair servicedelivery; and

establishing services or pilot projects that include best practices or replication by governmental,nongovernmental and international nongovernmental organizations.

1.9.6 Disabled peoples organizations

Disabled peoples organizations have a crucial role to play in the planning, initiation and ongoing

support o wheelchair service delivery. As organizations, they are able to advocate more eectivelythan individuals or users needs.

To be eective, disabled peoples organizations need knowledge and experience with appropriateproducts and services. Such organizations played an important role in preparing the Convention onthe Rights o Persons with Disabilities and will continue to be involved in its implementation in theuture. Wheelchair users have an important role to play in implementing Article 20 o the Conventionconcerned with personal mobility and o Article 26 addressing habilitation and rehabilitation.

The role o disabled peoples organizations in wheelchair provision includes:

dening users needs and barriers to equal participation; raising awareness o the need or eective wheelchair provision and nancing; consulting with policy planners and implementers in the development o wheelchair services; raising awareness o wheelchair services, and identiying people who need wheelchairs and

linking them with wheelchair services; monitoring and evaluating wheelchair services; advocating against inappropriate wheelchair provision, and that wheelchair services comply

with agreed guidelines; and supporting users by providing peer support and training.


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1.9.7 Users, families and caregivers

Users and their groups are at the centre o developing and implementing wheelchair provision(Fig.1.13). They can help ensure that wheelchair services meet their needs eectively.

The role o users includes: participating in the planning, implementation, management and evaluation o wheelchair

provision; participating in the development and testing o wheelchair designs; working within wheelchair services in clinical, technical and training roles; and supporting and training new users.

Some users permanently rely on members o their amily to assist with day-to-day activities oliving, while others may be more independent. Where a amily member or caregiver is responsibleor assisting a user on a daily basis, such as a parent o a child with cerebral palsy, he or she shouldalso be involved in all the roles listed above or users.

Family groups or parents, siblings and other relatives o children with disabilities are encouragedto undertake the activities listed under in Section 1.9.6.

Fi. 1.13. Uss oup

I Uada, a whchai poisio stakhods mti was hd i 2004, hostd b th Miist o Hath adsposod b th nowia Associatio o th Disabd. This aowd uss, disabd pops oaizatios,poducs, omt dpatmts ad doos to cotibut thi pspctis o th cut situatio o whchaipoisio, to a o o-tm oas, ad to pa how to achi thm. Th mti d to th appoitmt o a

whchai us as Whchai Pojct Oc withi th Miist o Hath. This psos ow xpic has ichdth pocss o whchai sic dopmt i th cout b bii a uss pspcti to th poic adimpmtatio .

Box 1.4. Wheelchair user at policy and implementation level in Uganda


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1

Summary

About 1% o a population need a wheelchair. Rights to wheelchairs are outlined in the United Nations policy instruments Convention on the

Rights o Persons with Disabilities and Standard Rules on the Equalization o Opportunities orPersons with Disabilities.

Using an appropriate wheelchair benets the health and quality o lie o the user, and can leadto economic benets or the user, the users amily and society as a whole.

Wheelchair provision includes the design, production and supply o wheelchairs and wheelchairservice delivery.

When developing approaches to wheelchair provision, it is necessary to consider nancial andphysical barriers or users, their access to rehabilitation services, and user education, inormationand choice.

There is a need or dierent types and sizes o wheelchair owing to the diversity o needs among

users. Stakeholders involved in wheelchair provision include policy planners and implementers;manuacturers, suppliers and donors o wheelchairs; providers o wheelchair services andproessional groups; national and international nongovernmental organizations and disabledpeoples organizations; and users, their amilies and caregivers.


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References

1. s s, J na, . Report o a Consensus Conerence on Wheelchairs or Developing Countries, Bangalore, India,

611 November 2006. c, Ii si pi oi, 2007 (://../

/wicc/wir_J08., 8 m 2008).2. Concept note. World Report on Disability and Rehabilitation. g, w h oizi, 2008 (://..i/

iiii/ii/____., 8 m 2008).

3. The Standard Rules on the Equalization o Opportunities or Persons with Disabilities. Preconditions or Equal Participation. n

yk, ui ni, 1993 (://..////i03., 8 m 2008).

4. Millennium Development Goals. n yk, ui ni, 2000 (://../ii, 8 m

2008).

5. Poverty reduction strategies. wi, dc, w bk. 2007 (://.k./wbsIte/external/topIcs/

extpoverty/extprs/0,,pK:384207~pK:149018~ipK:149093~sipK:384201,00., 8 m

2008).

6. Kizk m. 2003. Its not about wheelchairs. s i, ca, wii wi Ii, 2003 (://.iii./i//i_02., 8 m 2008).

7. r c, si hg. Wheelchair service guide or low-income countries. mi, tzi tii c oi t, ti uii, 2005.

8. r c .Atlas o orthoses and assistive devices: appropriate technologies or assistive devices, 3 . r, Il,

ai a oi s, 2006.

9. hi J. Patronage or partnership? Lessons learned rom wheelchair provision in Nicaragua [i]. wi, dc,

g uii, 2005.

10. iz sg . ci i i 3 i.Archives o Physical Medicine and

Rehabilitation, 2002, 82:14841488.

11. pii b, Z h. pi ii .Assistive Technology, 1993, 5:3645.

12. bi s, wij l.A study o the cost o rehabilitation o spinal cord injured patients in Sri Lanka. c, mii,1999 (://.ii..k/_i/hi_silktr., 25 m 2008).

13. diii riii t (dar). g, w h oizi, 2006 (://..i/iiii/

ii//, 26 J 2006).

14. Time or equality at work. Global Report under the Follow-up to the ILO Declaration on Fundamental Principles and Rights at

Work. g, Ii l o, 2003 (://.i.//i/declaratIonweb.download_blob/

v_dId=1558, 8 m 2008).

15. h e. Prejudice and dignity: an introduction to community based rehabilitation, 2 . n yk, ui ni

d p, 1999.

16. Global Survey on Government Action on the Implementation o the Standard Rules on the Equalization o Opportunities or Persons

with Disabilities. n yk, ui ni, 2006 (://../iiii/.?i=9&i=183, 8

m 2008).

17. Convention on the Rights o Persons with Disabilities. n yk, ui ni (://../iiii/.

?i=259, 6 m 2008).

18. mkj g, s a. wi i: i i- iii. Disability and

Rehabilitation, 2005, 27:591596.

19. s mJ, gk r. ai ii i iii iii. Rehabilitation

Psychology, 2005, 50:132141.

20. mn a, c ra, p J. cii i i i i

i i. I: Proceedings o the 28th Annual RESNA Conerence [cd-rom]. a, ga, resna, 2005:2527


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This chapter: outlines methods or designing or selecting a

wheelchair;

describes dierent types o wheelchair

production and supply;

sets out the advantages and disadvantages o

dierent wheelchair designs; and

suggests how to describe and evaluate

wheelchairs in terms o unctional perormance;

seating and postural support; and strength,

durability and saety.

to increase the quality and range of wheelchairs.

2 design and ProducTion


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d e s I g n a n d p r o d u c t I o n I 4 5

2

2.3 Wheelchair production and supply

Wheelchairs may be produced nationally or imported. To provide a range o wheelchairs, somecountries may choose to support both national production and importation. Each supply method

has an appropriate application (Table 2.1).

With many dierent needs within a region, a variety o supply methods may be suitable, the long-term goal being sustainable solution. It is recommended that all wheelchairs, irrespective o supplymethod, meet or exceed national wheelchair standards and be repairable locally.

When determining whether to acquire wheelchairs via import or local production, decision-makersare advised to balance a variety o actors. These include: the needs o local wheelchair users; the quality and variety o wheelchair models; the long-term reliability o supply o wheelchairs and spare parts; the possibility o infuencing the design, eatures, materials, etc.; the purchase price; the cost o repair and replacement; the eect on local employment and wheelchair production; coordination o supply with an overall plan or wheelchair provision; the amount and term o the unding available; and policies and strategies, including long-term sustainability.

Tab 2.1. Dit mthods o whchai poductio ad supp

National

production

Sma-sca Poductio o sma umbs o whchais usi oca aaiab matias adow tchoo poductio mthods to supp oca whchai sics.

la-sca Poductio o a umbs o whchais to supp whchai sicsatioa, ioa o oca.

Imported Usd

whchais

Coctio o usd whchais om hih-icom coutis, ubishd ad

suppid to ss-soucd sttis. Sctio o th coct mod is cucia i thispocss. Ot, such whchais ha b hospita-st whchais dsid otmpoa uss.

la-scapoductio

Whchais dsid ad poducd o sa o doatio i ss-soucd sttis,somtims assmbd oca.


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2.4 Functional performance

Functional perormance is how a wheelchair perorms or dierent users in dierent environments.The unctional perormance o a wheelchair is determined by its unique design and eatures. There

are many compromises to consider when designing or selecting or dierent uses.

This section provides inormation on the key eatures o a wheelchair that aects the main categorieso perormance and how to evaluate them. It also outlines compromises that need to be consideredwhen choosing dierent design eatures.

To meet the unctional perormance needs o individual users, a range o wheelchair designs andsizes are needed.

2.4.1 Wheelchair stability

Wheelchair stability aects how sae the wheelchair is, and how well the user can carry out activitiesin the wheelchair. Wheelchair tipping causes many injuries or users (4). Static stabilityrelates to the stability o the wheelchair when it is not moving. This determines

whether the wheelchair will tip over (where some wheels lose contact with the ground) whenthe user, or example, leans over to pick something up o o the ground or transers into or outo his or her wheelchair.

Dynamic stabilityrelates to the stability o the wheelchair when moving. This determines whetherthe user can ride over bumps or sloped suraces without tipping.

The design eatures used to increase wheelchair stability have secondary eects on other unctional

perormance characteristics. For example, moving the ront castor wheel orward increases stabilitybut reduces the manoeuvrability o the wheelchair in conned spaces. These relationships aredescribed below.

General stability is aected by the position o the combined centre o gravity o the user andthe wheelchair relative to its wheelbase. A way o increasing general stability and its associatedadvantages and disadvantages are shown in Table 2.2.

Tab 2.2. Aim: to icas stabiit i a dictios

Advantages DisadvantagesBy lowering the seat and thus the centre o gravity o the user

n It ma b asi o th us to ach objcts o th foo.n Th sat (ad th uss ks) wi b mo ik to t

ud dsks ad tabs.n Uss wi b mo ab to us thi t to assist with

popusio (i th a ab).

n Bi ow ma mak it had to ach objcts abo.n Th postu ma b ss comotab ad ma icas

th pssu o th uss sat (a caus o pssusos).

n Th uss pushi positio ma b wos ad accss toth had ims mo dicut.


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2

Apart rom seat height, stability in each direction is sensitive to several design actors, as describedbelow.

Rearward stability (resistance to tipping backwards) is aected by the rear axle position in relation

to the users centre o gravity. Ways o increasing rearward stability and their associated advantagesand disadvantages are shown in Table 2.3.

Advantages Disadvantages

By moving the rear wheel urther behind the users centre o gravity

n Som pop, such as som doub abo-kamputs, qui icasd awad stabiit bcausthi ct o ait is uth back.

n Icasd tdc to tu dowhi o sid sop.n Us wi ha poo accss to th had im ad a

shotd push-stok, maki it mo dicut to push

th whchai ad had o th upp xtmitis.n It wi b mo dicut to pom a whi to

otiat obstacs.n Whchai is had to maou i cod spacs.

By using anti-tip devices to prevent a wheelchair tipping over backwards ( see Fig. 2.3)

n Ati-tip dics ca b usu o som uss who austab o a ai to pom whis (whbth us aiss th ot casto whs ad baacs oth a di whs).

n Most ati-tip dsis stict th whchais abiit tota o u suacs (such as kbs o dips).

Tab 2.3. Aim: to icas awad stabiit

Note: A ba, backpack o a wiht hai bhid th whchai wi mo th ct o ait back ad mak th whchai mo ik to tip backwads.

Fi. 2.3. Ati-tip dic


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Forward stability is aected by the size and position o the ront castor wheel in relation to theusers centre o gravity. Ways o increasing orward stability and their associated advantages anddisadvantages are shown in Table 2.4.

Sideways stability is aected by wheelchair width. The urther out to the side o the wheelchairthe ront and rear wheels touch the ground, the more the chair will resist tipping over sideways.

Ways o increasing sideways stability and their associated advantages and disadvantages are shownin Table 2.5.

Tab 2.4. Aim: to icas owad stabiit


By moving the ront castor wheel orward o the users centre o gravity

n Th whchai wi sist tippi owad wh thcastos a stoppd sudd b a objct th caoto o.

n lss wiht o th ot whs wi duc th oisistac o th ot whs, aowi th whchaito o mo asi.

n Oa whchai th is o, maki it had tomaou i cod spacs.

By using larger ront castor wheelsn Fot casto siz siicat acts damic stabiit;

with a ot whs th whchai wi b ab too o a obstacs without bi stoppd adtippd owad.

n la ot casto whs d mo oom to swi; thwhchai dsi wi d to b much o o widto aow oom o th uss t.

Note: I th ootsts a ahad o th ot whs, a wiht pacd o th ootsts (a ha chid, o xamp) ca tip th whchai owads..

Tab 2.5. Aim: to icas sidwas stabiit


By increasing the width o the wheelchair

n Poids mo stabiit.n Comotab sati.n Btt o owiht pop.

n A wid whchai is mo dicut to t thouhaow doowas.

n not cit o pushi ad had o upp xtmitis

bcaus th us has to ach out to push th had ims.By adding camber to the wheels (see Fig. 2.4)

n Camb bis th whs cos to th us ad mo ii with th uss owad push stok, thus maki itasi to push. This ca b spcia hpu o wom,who usua ha aow shouds but wid hipstha m.

n Tactio is btt wh tasi sops.

n A wid whchai is mo dicut to t thouhaow doowas.

n Camb icass th width o th whchai wh it isodd.


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2.5.3 Backrests

The backrest provides users the necessary postural support. It needs to be o dierent heights butusually available in two sizes as shown in Fig. 2.12 and Fig. 2.13.

Some users require more support rom a backrest than others. For some users, a high backrest canreduce their ability to propel themselves eectively. Backrests may be sling or solid types with oamcushioning and upholstery. Recommendations or backrests are given in Box 2.7.

2.5.4 Footrests

The ootrest provides users with support or their eet and legs. Footrests must be individuallyadjusted or each user. Correctly adjusted, the ootplate reduces pressure on the users seat andputs the user in a healthy sitting posture. Footrests may also include a cal strap to keep the oot onthe ootplate. Sucient ground clearance needs to be maintained to prevent the ootrest hittingobstacles or catching and tipping the wheelchair on uneven ground. The height o the ootrestshould be adjustable. Footrests need to be long or wide enough to support the oot but, at thesame time, should not create diculty while olding or moving around. For other perormanceactors related to the ootrest see Table 2.10.

Fi. 2.12. low backst Fi. 2.13. Hih backst

n Th a btw th sat adth backst (sat to back a)

shoud b btw 80 ad 100ds.

n Dit backst hihtsshoud b aaiab.

n Th backst shoud suppot thoma cuatu o th spi.Th midd o th back shoudb ab to st uth back thath back o th pis.

Box 2.7. Guidelines or backrests


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2.5.6 Rear wheels

The rear wheel should be in a position that allows the user to have the best push stroke as possibleand keeps the user saely balanced according to his or her skill level and ability. The position o the

rear wheel should allow the user to have a good push stroke and provide the necessary stability.

2.5.7 Evaluating seating and postural support elementsIt is recommended that wheelchairs and cushions be evaluated based on the seating and posturalsupport perormance measures, and the results be available to the users and purchasers. The areasin which a wheelchair and cushion should be evaluated or reported on are: seating dimensions and adjustability cushion type and characteristics.

Seating dimensions and cushion characteristics tests and reporting techniques are covered in ISOstandards 7176-7 and 16840-2 (5).

2.6 Strength, durability and safety

The goal o this section is to help dene what makes a sae and reliable wheelchair, and how toevaluate and report these attributes to stakeholders (see Box 2.8). When a wheelchair ails, the useris not only at risk o injury but may not be able to go anywhere or do anything until the wheelchairis repaired or replaced.

Apart rom ensuring that the wheelchair is sae and eective, evaluating strength and durability isa way o gathering important inormation that can be useul or all stakeholders users, designers,providers, manuacturers and unding agencies. Keeping accurate records o the results o strengthand durability tests will help wheelchair designs evolve so that their quality and eectivenesscontinually improve.

n A whchais shoud mt th stth, duabiit ad sat quimts o us(s) i thi ow iomt(s).n It is commdd that ach cout dop its ow whchai stadads to su a asoab quait, o

istac b usi th ISO 7176 sis o stadads as a basis. Wh dopi atioa stadads, it is impotatto cosid th wihts ad sizs o th uss, tpica us, aaiab tsti quipmt ad aaiab whchaitchoo. Th stadads shoud b aaiab to mauactus, puchass ad uss, ad b iwd om tim totim.

n A whchais shoud b auatd basd o th stth, duabiit ad sat quimts st b th cout, adth suts shoud b aaiab to uss ad puchass.

Box 2.8. Strength, durability and saety guidelines


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2

Fi. 2.16. Tsti dic

2.6.1 Requirements

A wheelchair should be strong and durable enough to withstand the wear and tear placed on it bythe user and to keep the user sae. Wear and tear consists o:

static orces impacts atigue stresses rom use over time.

Simple testing device can be developed to ensure strength and durability, as shown in Fig. 2.16.

The fammability o the wheelchair, the eectiveness o the brakes and the saety o the suraceson the wheelchair also aect the saety o the user.


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Table 2.12 provides a list o ways in which wheelchairs are used and the related strength anddurability requirements or each component.

Tab 2.12. Whchai uss ad quid duabiit ad stth quimts

Part Need or strength, durability and saety

Footrest Footst shoud od with a asoab amout o oc.

Footst shoud ot bak o bd wh usd to it us ad whchai.

Footst shoud ot bak o bd wh additioa passs o packas a oadd.

Footst shoud ot bak o bd wh hitti a objct such as a wa o cub.

Brake Baks shoud stop a whchai om sidi wh o a ici.

Baks shoud ot sudd as whi i us.

Armrest Amst shoud b moab with a asoab amout o oc.Amst shoud ot bak o bd ud th uss bod wiht.

Amst shoud ot bak o bd wh usd to it us ad whchai.

Push handles Push hads shoud ot bak o bd wh usd to it us ad whchai.

Hadip shoud ot sid o o push had wh us is bi assistd up stais o cub.

Frame Fam shoud ot bak o bd wh usd o u tai.

Backrest and seat Backst, sat ad am shoud ot bak o bd dui tasas o whi idi ou tai.

Rear wheel and axle Fam, whs o axs shoud ot bak o bd wh us os o a oma kb.

Whs, axs o wh-mouti hadwa shoud ot ai wh us dops o kb at a.

Axs o wh-mouti hadwa shoud ot bak o bd wh ud tpica ocs.

Castor assembly Casto shoud ot ai wh th casto wh hits a objct (.. a cub).

General Suacs shoud ot ha shap ds, shap poits o pich poits.

Whchai shoud ot b fammab, i.. asi combustib matias shoud ot b usd.

Whchais shoud b quippd with ot ad a fcti sticks o sis o icasdoad sat.

Miscellaneous Tippi s shoud ot bak wh assistat uss s to tip us back.

Had im shoud ot bak o bd wh it hits a objct.

Whchai shoud ot bak wh it as o is doppd b had oadi o uoadi itom bus o ca.

Fatigue test Whchai shoud ot bak i oma us.


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Long-term ollow-up. Ater workshop and user trial testing has proven the wheelchair design is saeand eective, the wheelchair will be put into production and then sent to wheelchair services orprovision. A sample o wheelchairs should be ollowed over time. This could be done, or instance,by contacting selected users six months, one year and three years ater they received the wheelchair

to determine the typical ailures and maintenance requirements and their general opinion on theunctional perormance o the wheelchair.

Recommendations or user trials and long-term ollow-up are given in Box 2.9.

Summary

Governments are recommended to develop and adopt national wheelchair standards to ensurea reasonable quality o wheelchairs, or instance by using the ISO 7176 series o wheelchairstandards as a basis.

It is recommended that the national wheelchair standards are applicable to all wheelchairssupplied in a country, whether produced within the country or imported.

General design considerations include user health and saety, strength and durability, suitability

or use and production methods. Wheelchair designs should be evaluated in three areas: unctional perormance; seating and

postural support; and strength, durability and saety. Results o the evaluation and testing o wheelchairs must be available to users and purchasers. A variety o actors need to be considered when determining whether wheelchairs should be

acquired through national production or importation. Wheelchairs and spare parts need to be available, accessible and aordable.

n Whchais shoud b tstd b uss i th cotxt ad iomt i which th wi b usd, bo th asuppid to sics o uss (bo poductio o bo a-sca puchas) (7,8).

n lo-tm oow-up studis shoud b usd to su th whchai is sa ad cti o o piods o us (9).

Box 2.9. Recommendations or user trials and ollow-up


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The service delivery guidelines: suggest strategies or introducing wheelchair

service delivery;

describe basic wheelchair service delivery;

provide practice guidelines;

suggest roles or the personnel involved; and

make recommendations on monitoring and

evaluation.

to ensure that users receive appropriate wheelchairs.

3 service delivery


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Wheelchairs changing lives

Box 3.1.

Tstimoia om a us i romaia

Ciprian is 25 years old and lives in

Santu Gheorghe, Romania. Three

years ago he became paraplegic

ater alling rom a roo whileat work and lost any hope that

he would ever have a normal

and active lie again. Some time

ater the accident, however,

he heard about a local

nongovernmental organization

that provided support or users.

Through the wheelchair service

run by the organization, Ciprian

received an active-style manual

wheelchair that was tted or him.

He was also invited to participate

in a peer group training camp.

Ciprian says: Once I got there I realized that I could have an independent lie. Through

the peer group training, I learnt to use my wheelchair very well. I also had the chance to

talk with other users involved in the programme. At the end o the camp, I was asked i I

would like to become a peer group trainer. O course, I was very happy about this chance

that had just been oered to me. In January 2006, I started my work as an instructor.

Through my wheelchair, and peer training, I have recovered the independence I thought

I had lost because o the injury. In addition to my peer group training work, I take part in

various competitions and sports activities or people in wheelchairs. Working with people

with disabilities makes me eel that I am useul again and that I nally have a normal lie

ater I had had such a hard time overcoming the health problems brought about by the

injury.


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In addition to the key unctions listed above, providers o wheelchair services will play a role in: awareness: disseminating basic inormation about the needs or and beneits o using a

wheelchair (this can also be done by personnel involved in community-based rehabilitation,health and education programmes as well as by disabled peoples organizations); and convincing

policy-makers about the benets o investing in wheelchair provision rather than leaving peoplewith disabilities to survive on charity;

identifcation: using a screening tool to identiy those who can benet rom available services; awareness o reerral networks and suppliers: promoting the role o wheelchair services,

including participation in activities aimed at educating reerral networks and raising theawareness o suppliers and unding agencies regarding the role and importance o wheelchairservices;

sustainability: developing sustainable nancial solutions or the continuing provision o mobilityequipment through wheelchair services;

training: providing or supporting the training o wheelchair service personnel; standards: raising wheelchair standards within the country or region through being aware o

current wheelchair availability and advocating or improvements in and a greater variety owheelchair products; and

accessibility: supporting or acilitating the adaptation o homes (including toilets, urniture andttings) and public buildings and places, and lobbying or a barrier-ree environment.

Strategies

Wheelchair service delivery requires careul planning and management o resources. There ollowa number o strategies that can be employed to initiate or urther develop wheelchair services.

Providing wheelchairs together with servicesThere are dierent methods o wheelchair supply to meet the range o contexts in which userslive (see Sections 1.7 and 2.3). Whatever the method or structure chosen, it is important to deliveressential wheelchair services (2,3).

Utilizing existing personnelIt is not necessary to create a new proession to provide wheelchair services. With additionaltraining, many health and rehabilitation personnel would be able to take on the duties required orbasic wheelchair service delivery. For example, community health care workers, community-basedrehabilitation workers, nurses, physiotherapists, occupational therapists, orthotists and prosthetistscould be trained to ull the clinical role in wheelchair services. Likewise, with additional training,

skilled cratspeople, mechanics and orthotic and prosthetic technicians could ull the technicalrole.

Meeting the needs of users at community levelSome aspects o wheelchair provision can be carried out in the community, through a network ocommunity-based organizations (or example rehabilitation and health programmes) supportedby a local wheelchair service centre. The personnel o the community-based programmes couldbe trained by wheelchair service personnel in basic service delivery. This system o service deliverywould best suit users who require a basic wheelchair, without modications, postural support orpressure management care.


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s e r v I c e d e l I v e r y I 7 3

3

Users with more complex needs are likely to require the skills o personnel with greater trainingthan can be provided to all community-level personnel. This need can be addressed by outreachservices coordinated by the wheelchair service centre. I outreach services are not developed,these users would need to travel to the wheelchair service centre. However, once provided with

an appropriate wheelchair, they may be supported by community-based personnel.

A wheelchair service can make use o the skills, technologies and capacities o local industries. Forexample, bicycle repair shops can also repair wheelchairs, and tubular urniture makers have thebasic skills and knowledge to build wheelchairs.

Table 3.1 provides a summary o a two-tier wheelchair service approach. This shows a possiblemodel linking a wheelchair service centre with a number o community-based wheelchair services.To provide adequate support to the community-based centres, it may be necessary to rst developthe wheelchair service centre. Alternatively, a collaborative eort between existing community-based centres could work towards the development o the wheelchair service centre. In either

case, the development process should be based on a needs assessment and other aspects o thelocal context.

Tab 3.1. Dsciptio o a two-ti whchai sic appoach

Characteristics Key unctions

Whchaisicct

Ct-basd.Facilities (possib shad with xisti hath ohabiitatio sics): ciica ad us taiiaciitis; wokshop aciitis.

Staf: ddicatd whchai sic ctpso taid to mt th ds o a uss.

Whchai sic di o a uss.Commuit outach; iki with commuit-basd whchai sics ad a twoks.Taii, suppot ad supisio o commuit-

basd whchai sics ad pso.educatio o a soucs.liki with ducatio, mpomt ad oth kdopmt sctos.

Commuit-basdwhchaisics

Ct-basd, with som whchai sicdi caid out ti i th commuit.Facilities (shad with oth commuit hathad habiitatio poamms): accss to ciic,us taii aciitis, basic wokshop aciitis.Sta: commuit hath ad habiitatio

woks taid i basic whchai sicdi, supisd ad suppotd b whchaisic ct pso.

Whchai sic di o uss quiibasic whchais without custom modiicatios opostua suppot compots.Idtiicatio o uss with compx ds, ada to whchai sic ct.Wh appopiat, suppot o uss with mo

compx ds o oow-up, maitac adpai i th commuit.Suppot o accssibiit, icudi adaptatio ouss iomt such as wid doos ad amps.


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Integrating wheelchair services into existing health or rehabilitation servicesA wheelchair service centre or department can be established within existing rehabilitation services.Such services are already likely to have users accessing the service or health or rehabilitation needs.They would thereore already have much o the inrastructure required. Examples o rehabilitation

services well suited to the integration o a wheelchair service include prosthetics and orthoticsservices and spinal injury centres.

Wheelchair services could play a dual role, providing wheelchairs directly to users and supportingbasic services in the community through partnerships with community-level programmes andorganizations.

Stakeholders and resources

Stakeholders directly involved in the planning, implementation and participation in service deliveryinclude: users and their amilies or caregivers; government authorities, including ministries responsible or health, social welare and education

and other relevant departments and local authorities; existing health and rehabilitation services (including reerral networks) managed by governmental,

private, nongovernmental, international nongovernmental or disabled peoples organizations; supporting organizations providing technical input or unding; rehabilitation personnel and their organizations; and wheelchair service personnel.

The resources required to implement the recommendations include:

a reliable supply o wheelchairs that meet agreed standards; access to dierent types and sizes o wheelchair to meet the varied needs o individual users; personnel with training in wheelchair service delivery; acilities (which may be shared with existing rehabilitation or health services): clinicalfacilitiesprovidingsucientspaceforassessment,basicusertrainingandstorageof

wheelchairs, and workshopfacilities,particularlywheremodications towheelchairsareoeredor postural

support is provided; materials or wheelchair modications and custom components; and unding to support wheelchair service delivery (products and services).


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I Papua nw guia, a stimatd 50 000 pop d a whchai. Thouhout 2003 ad 2004, omta hathad habiitatio oaizatios ad atioa ad itatioa oomta oaizatios dopd a stat o

whchai poisio. As a sut, a piot whchai sic twok, cos ikd to th xisti hath ad habiitatiosics, was st up.

Th whchai sic twok cosists o a ioa whchai sic suppoti ou satit whchaisics. Th ioa sic is basd at th natioa Othotics ad Posthtics Sic i la. At th ioa sic,tchica pso om th natioa Othotics ad Posthtics Sic tam ad phsica thap pso om lasAau Hospita toth ca out assssmt, psciptio, tti, us taii ad oow-up. Th natioa Othoticsad Posthtics Sic poids pai sics o uss. This mixtu o ciica ad tchica aciitis has mad thstti up o th whchai sic ati as, ad th ct poisio o ddicatd pmiss o th sic hasi it a sto idtit.

Two o th satit sics a basd i oca hospitas, o i a oca posthtic uit ad o i a oca commuit-basd habiitatio sic. Th commuit-basd habiitatio ik with ach sic is sto. Th commuit-basd habiitatio twoks poid xct a, ad th pso wok with hospita-basd pso topoid uss with a whchai.

Taii i basic whchai sic di o a o th ciica ad tchica pso iod i th sictwok was poidd o two wks b th itatioa oomta oaizatio Motiatio. Futh suppoto both ciica ad tchica pso o o a was poidd b a out phsiothapist.

Th twok has th capacit to poid 25 whchais p moth. This is sti ot sucit to mt th ds iPapua nw guia. How, thouh th succss o this piot xcis i usi xisti sics ad pso, muchhas b at about th o o whchai sics. I utu, a stakhods a k to s th stabishmto mo satit sics, as w as a icas i th capacit o th twok to mt th ds o uss with mocompx ds.

Box 3.2. A wheelchair service network in Papua New Guinea


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3.2 Wheelchair service delivery

3.2.1 Steps in service delivery

The unctions o wheelchair services are described in Section 3.1. Wheelchair services are commonlydelivered in a sequence o steps. A summary o eight key steps typically involved in wheelchairservice delivery is given in Table 3.2 (4,5). Further details about each step and recommendationson good practice are provided in Section 3.3.

Tab 3.2. K stps tpica iod i whchai sic di

Step Summary

1. ra adappoitmt

Th sstm o a wi dpd o xisti sics i thcout. Uss ma s- o b d thouh twoks

mad up o omta o oomta hath adhabiitatio woks o outs woki at commuit,distict o ioa . Som sics ma d to actiidti pottia uss i th a ot aad cii asocia o hath ca sics o paticipati i schoo, wok ocommuit actiitis.

2. Assssmt each us quis a idiidua assssmt, taki ito accoutist, ocatio, hom iomt ad phsica coditio.

3. Psciptio(sctio)

Usi th iomatio aid om th assssmt, a whchaipsciptio is dopd toth with th us, ami mmb

o cai. Th psciptio dtais th sctd whchaitp, siz, spcia atus ad modicatios. Aso dtaid isth taii th us ds to cti us ad maitai thwhchai.

4. Fudi adodi

A udi souc is idtid ad th whchai is odd omstock hd b th sic o om th suppi.

5. Poductppaatio

Taid pso ppa th whchai o th iitia tti.Dpdi o th poduct ad sic aciitis, this ma icudassmb, ad possib modicatio, o poducts suppid bmauactus o poductio o poducts i th sic wokshop.

6. Fitti Th us tis th whchai. Fia adjustmts a mad tosu th whchai is coct assmbd ad st up. Imodicatios o postua suppot compots a quid,additioa ttis ma b cssa.

7. Us taii Th us ad cais a istuctd o how to sa adcti us ad maitai th whchai.

8. Foow-up,maitacad pais

Foow-up appoitmts a a oppotuit to chck whchait ad poid uth taii ad suppot. Th timi dpdso th ds o th us ad th oth sics that a aaiabto thm. Th sic ma aso o maitac ad pais otchica pobms that caot b asi sod i th commuit.It is appopiat to ca out oow-up actiitis at th commuit as much as possib. I th whchai is oud to b o oappopiat, a w whchai ds to b suppid stati aaiom stp 1.


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Tab 3.3. Postua ds o uss atd to th d o pso ski ad suppot

User Needs

Users o manual wheelchairs

without modifcations

Chid o aduts who casit w without a postuadomitis o abomaitis.

Mobiit ad postua suppot o comot,uctio ad th ptio o postuapobms associatd with pmatwhchai us.

Mobiit ad postua suppot poiddthouh a w-ttd whchai ad satcushio.

Users o manual wheelchairs

with supportive seating

Chid o aduts withmid to modat postuadomitis o tdcis.I uaddssd, thsdomitis wi imit comot,hath ad uctio.

Mobiit ad postua suppot to stabiizpostu o comot, uctio ad ptioo uth postua pobms.

Suppoti sati poidd thouhidiidua modicatios to a basicwhchai, o a spciaizd sati sstm.

Users o complex supportiveseating and mobility equipment

Chid o aduts withcompx, xd postuadomitis. e withsuppot, ma caot sitoma.

Mobiit ad idiidua pscibd adcustomizd whchais to poid postuasuppot ad accommodat xd domitis.

Increasedneedo

fskilla

ndsu

pp

ort

3.2.2 Understanding individual user needs

When planning wheelchair service delivery, it is important to recognize that each user has a uniqueset o needs. These needs can be categorized as:

physical the users health situation and postural and unctional needs; environmental where users live and where they need to use the wheelchair; and liestyle the things users need to do in the wheelchair to lead their chosen way o lie.

Physical needs. Some users will have a more complex mix o physical needs than others. Users withpostural deormities, reduced skin sensation and problems with muscle tone (or example spasticity)will require an assessment conducted by personnel with appropriate skills and knowledge. Theseusers will also require more requent ollow-up and support. Three degrees o postural need andtheir relationship to the skill and support required rom the personnel are described in Table 3.3.


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Environmental and liestyle needs. These actors require consideration during the assessment.They will infuence the choice o a wheelchair, based on perormance characteristics, durability andother eatures. This is discussed in Chapter 4.

3.3 Good practice in wheelchair service delivery

This section o the guidelines can be used to help in planning and initiating wheelchair servicesand in evaluating existing services. Recommendations are presented in nine areas: good practicein overall service and or each o the eight key steps in wheelchair service delivery.

3.3.1 Overall service

Good practice in wheelchair service includes the ollowing. Wheelchair services recognize users as clients o the service and adopt a client-centred approach.

This means, inter alia, that: users receive informationabout theprocessthewheelchair servicewilluse toprovidea

wheelchair, and the rights and responsibilities o the user in this process; usersareactivelyinvolvedasmembersoftheserviceteaminallstepsleadingtotheprovision

o their wheelchair; and servicesactivelycollectfeedbackfromusersabouttheiropinionoftheserviceandhowitmay

be improved. The service is equally accessible to all users, regardless o gender, age, ethnicity, religion or social

status. The service has personnel trained in its clinical, technical and training roles, who work closely

with users to provide advice, assessment, prescription, tting, training and ollow-up. The service has a designated service manager or coordinator. A reerral network is in place. The service is well integrated with other rehabilitation and health services. Services are knowledgeable about the range o wheelchairs available locally. Services are able to oer more than one type o wheelchair, giving the user a choice based on

the assessment.

How many users require more than basic wheelchair provision?

Owi to a a ack o statistics, it is ot possib to stat accuat how ma uss a ito ach o th oupsdscibd i Tab 3.3. How, i a su o 147 uss coductd at th Wst Cap rhabiitatio Ct i SouthAica i 2006, it was oud that 58% o uss quid som om o whchai modicatio o basic postua suppot.Som 22% quid compx postua suppot, whi o 20% w ab to us a basic maua whchai without amodicatio.

A supiso chi phsiothapist stats: Sic ou sic ba, w ha oud that ma uss d mo thajust a basic whchai. Ma ha domitis om ii so o without a whchai ad ow d thi whchai

modid so that it ts thm. W aso ha mo ad mo chid with cba pas comi to us, ad th dwhchais with xta postua suppot.

Box 3.3. Needs or wheelchair modications and postural support additions in South Arica


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3.3.5 Funding and orderingObjectiveThe objective o good practice in unding and ordering is to order or procure the selected wheelchair

or the user, as early as possible.

FundingFollowing prescription, it is possible to closely estimate the cost o the product being recommended.For most services, it will be essential to ensure a unding source has been identied beore an ordercan be placed or equipment. Wherever possible, this should be in the hands o administrative ratherthan clinical or technical personnel. See section 5.4 or more inormation on unding.

OrderingWhen not in stock, wheelchairs need to be ordered rom an external supplier or procured romthe wheelchair service workshop, which usually maintains a stock o dierent sizes and types owheelchair.

3.3.6 Product preparation

ObjectiveThe objective o good practice in product preparation is to prepare the wheelchair or the tting,including modications or custom postural support components.

n I a whchai is ot immdiat aaiab, sics iom th us wh th whchai wi b ad o tti.n Sics maitai a stock o whchais ad compots to su ast di tims.n Sics coua suppis to dop ca od oms ad pocdus.n Sics a with suppis o di tims ad aim to miimiz das.n Sics su odi is comptd withi two woki das o compti th uss psciptio, poidd that

udi is i pac.n

Sics ha a sstm i pac to moito pdi ods om suppis.n Sics ha a sstm o poidi dback to suppis about quait issus.

Box 3.7. Good practice in ordering

n each whchai bi ppad is abd with th uss am ad a sia umb o ba cod.n Modicatios to whchais (pmat ati th am o a compot o th whchai) a caid out

o b pso with th appopiat kowd ad skis, sic a such modicatio ma ha stuctua aductioa impicatios.

n Th poductio ad istaatio o custom sati sstms o idiidua postua suppot compots shoudb caid out b pso with th appopiat kowd ad skis. This wok shoud aso b do i coscoaboatio with th assssmt pso.

n A mobiit quipmt is chckd o quait ad sat bo th us tis it.

Box 3.8. Good practice in product preparation


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3.3.8 Training of users, families and caregivers

ObjectiveThe objective o good practice in training is to ensure that all users are given the inormation and

training they need to be able to use their wheelchair saely and eectively.

Key areas o user training include: how to transer in and out o the wheelchair, how to handle the wheelchair; basic wheelchair mobility; how to stay healthy in the wheelchair or example prevention o pressure sores; how to look ater the wheelchair and cushion and, i appropriate, dismantle and reassemble the

wheelchair; and who to contact in case o problems.

Fi. 3.3. Whchai mobiit taii with p tai

n A us taii chckist is comptd toth with th us, coi th skis th us ds to ha i od opioit. Th chckist is usd b th tai, ad as ach ski is tauht ad dmostatd b th us it is chckd o.

n Wh possib, p tais (acti uss with sto whchai skis ad taii i how to tach ad suppototh uss) poid basic us taii, with supisio b ciica pso.

n Whchai sics ik cos with a us oups i th commuit, poidi p taii to stthtaii i at th sic.

n

Witt o isua matias, icudi pamphts o posts i oca auas, a usd to assist th taii o uss.

Box 3.10. Good practice in basic training o users


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Management roleFor a wheelchair service to operate eectively, a designated manager is critical. The managerensures a ramework is in place to enable the wheelchair service to operate. This includes adequatestang, acilities, unding, products, reerrals and appointment systems. Managers also play a key

role in promoting wheelchair services. The manager thereore requires a thorough understandingo wheelchair service delivery in addition to general management skills.

The duties o wheelchair service managers should include: building awareness o wheelchair service delivery among all stakeholders; developing a reerral network through promotion o the wheelchair service and its unctions; organizing training opportunities or reerral network personnel; ensuring the service is accessible to all users within the service area, including women, children

and minority groups; managing waiting lists; identiying and securing sources o unding to support the service; acilitating the development and training o service personnel; evaluating the eectiveness o the service in meeting users needs; continuously improving service quality; developing links with disabled peoples organizations and community-based rehabilitation

programmes; and assisting in the ormation o wheelchair users groups.

Clinical roleClinical personnel work directly with the user in assessment, prescription, tting and ollow-up.Ideally, the clinical personnel work closely with technical personnel, particularly on prescription

and tting.

The main duties o clinical personnel include: wheelchair service delivery, ollowing the eight-step process described in Table 3.2; quality control to ensure equipment is adjusted correctly and is sae or each user; training users in mobility and health issues, or supervision o such training provided by a

trainer; ollow-up with users to ensure that equipment continues to be appropriate to their needs; record keeping and documentation; education o reerral network personnel; keeping up to date with the range o available wheelchairs; and

participation in overall service evaluation.


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Wheelchair Guidelines (en for the Web)

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