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Wheelchairs for MS Patients
By: J. Kesselring, M.D., Professor - President of the Medical Council of the Swiss Multiple Sclerosis Association
In contrast to cases involving sudden disability where one could normally look forward to an improvement, mobility aids take on a new meaning in the context of diseases that tend toward chronic progression. With MS, it is particularly difficult to decide when to recommend the use of a wheelchair and which model to use. The accompanying counseling is equally problematic.
Patients suffering from conditions that tend toward progressive stages of disability in adulthood are particularly reluctant to make use of mobility aids. They are afraid that by giving in to weakness, they will reach a point of no return. This attitude is true of the vast majority of MS patients.
It would be beneficial to engage in a series of consultations with a supportive doctor in order to determine whether the effort required to walk is leaving the patient with enough energy to carry on with his daily routine. Walking with the aid of two sticks should not be so strenuous as to leave the patient completely drained of strength. It is worth bearing in mind too, that the use of two walking sticks precludes carrying whereas the use of a wheelchair leaves the hands free.
On the other hand, it is known that MS deterioration, from stretching to contracting spasticity is linked to the inability to stand. Lack of physical activity worsens this spasticity. This can lead to osteoporosis (reduction in bone mass) and further complications. The goal is to maintain mobility, maximize stability and safety, while reducing the effort required by the patient.
A wheelchair must be adjusted to cater to an individual's needs, with regard to all technical and therapeutic considerations. There can be dire consequences if a wheelchair is chosen and ordered "blind" from the insurer's warehouse. At the same time, the patient should complete a training course. This should cover use of the wheelchair as well as extra-wheelchair activities, the most important of which are the daily standing exercises. These are intended to stretch important muscle groups, and can be effective or even prevent the onset of contractures (the disjunction of a joint leading to limited range of movement). Standing significantly minimizes the effects of spasticity and osteoporosis. It also facilitates therapeutic activity outside the wheelchair. There are numerous books and videos available as an accompaniment and guide to courses for this type of home therapy.
Specific wheelchair training includes the strengthening of the shoulder and arm muscles and instruction in transfers. When transferring, it is recommended that MS patients keep their feet on the ground.
Wheelchairs for MS patients should be light, maneuverable and collapsible. Driving the wheelchair manually is often the patient's only means of stimulating his circulation. When prescribing an electric wheelchair, it is especially important to stress the need for regular active therapy and standing exercises. Suitable models allow for a combination of the two. Another alternative is a particularly maneuverable electric scooter.
Before making any decision, examine the wheelchair's component parts. Each of these parts plays an important role in terms of suitability.
Hard rubber tires, especially on the front wheels, make maneuvering much easier, particularly inside the home. Pneumatic tires are more suitable outdoors as they provide improved shock absorption. The choice of wheels depends on whether the wheelchair is to be used indoors or outdoors. Continuous use of the wheelchair, both in the home as well as outside, would justify acquiring two models. As with quadriplegics, gloves should be worn to enable the user to grip the wheels themselves as opposed to the metal frame.
The height of the backrest depends on individual torso stability. Ideally, the backrest upholstery should be tightened in line with the needs of the user. In extreme cases, this can be achieved by using a detachable board. A cushion may prove useful in countering extension (stretching) on the pelvic lower spine area. The cushion must not, however, push the patient too far forward, or he'll continuously have to prop himself up on the armrests. The backrest should be tilted slightly backwards, if needed.
The armrests should be both detachable and height adjustable. Armrests that are set either too high or too low lead to bad posture and shoulder complaints. It is important that the armrests are not too long. The user must fit comfortably under tables, etc.
Slack seats are a cause of leg adduction (pressing together). By using a removable board or special seat cushion, it is possible to avoid this condition. Simply placing a wedge cushion onto the seat is not sufficient to counter the stretching spasms in the lower spinal area, which results in poor posture with many MS patients. The only effective remedy is actively flexing the hips, an exercise that must be practiced unaided. The use of so-called antidecubitus cushions (those filled with air or gel) is also appropriate. They do allow the patient to sit in comfort but can lead to balancing difficulties. Prevention of decubitus (severe bedsores) is possible through incorporation of an exercise program.
The wheelchair should be equipped with footrests. Folding them to the side and/or removing them altogether when transferring should be a simple process. Footrests serve to minimize injuries while preventing contractions and increased extensor spasms. In some cases, a broad cushioned calf support may be used to counter flexor (contract) spasticity and/or decubitus caused by the calf strap.
WHEELCHAIR TABLES AND HEADRESTS:
These are only of benefit when dealing with ataxia and/or quadriplegia.
Attention to the above details will somewhat alleviate the frequent and often painful posture problems experienced by MS patients in their wheelchairs. Still, the main cause of bad posture is the tilt of the pelvis and resulting flexion in the lower spine. As it bends, the lower spine induces increased chest kyphosis (pushing forward of the spine). This forces the patient to over-stretch the neck in an attempt to hold his head straight.
The effects of this chain reaction are compounded when the wheelchair user has to look up to people standing above him. The stretching of the spine within the neck intensifies spastic flexing in the arms and extension in the legs. The increased chest kyphosis is only compounded by the use of a wedge cushion. This prevents the user from bringing his shoulders forward as needed in order to propel the wheels. The remedy lies in hip flexing exercises with the thighs parallel to the seat or floor and the knees and feet more or less forming a right angle.
I am convinced that the clinical symptoms of Multiple Sclerosis are in part, a direct result of complications that set in after the initial onset of the disease and could therefore be prevented. These include the extension spasticity of the legs accompanied by contractures and a host of painful conditions that are often ignored when dealing with MS. As a result, these symptoms are too seldom the specific target of treatment.