What are the indications for a power chair in a patient with progressive mobility impairment, using a standard manual wheelchair (MW) since March, experiencing weakness, fatigue, and right shoulder pain from pushing the chair, despite physical therapy (PT) and a shoulder brace, and seeking a power-assist option for improved independence and safety?

From the Guidelines

I strongly recommend a power-assist wheelchair for this patient based on their progressive mobility issues, shoulder pain from manual wheelchair use, and desire to maintain independence. The patient has demonstrated appropriate use of their current manual wheelchair since March, primarily for community mobility while maintaining some function at home. The development of right shoulder pain despite trying a shoulder brace indicates that continued manual propulsion may lead to further injury and potentially limit the patient's independence. Since the patient reports physical therapy is helping, this should continue alongside the new mobility device. A power-assist option would provide the necessary support while allowing the patient to maintain some physical engagement, striking a balance between complete power mobility and manual propulsion. This approach addresses both the medical need (reducing shoulder strain) and functional goals (maintaining independence and safety during community activities) as supported by the guidelines for adult stroke rehabilitation and recovery 1.

The patient's situation aligns with the recommendations for the use of adaptive devices and wheelchairs to maximize independent functioning after stroke, considering the type and level of functional deficit, degree of achieved adaptation, and the structural characteristics of the living environment 1. The prescription of a wheelchair (manual or powered) in the community can increase participation and improve quality of life, and many stroke patients can learn to use powered wheelchairs safely with appropriate training 1.

Key considerations for the patient include:

• Evaluating the most appropriate power-assist system based on their specific needs, home environment, and transportation requirements.
• Continuing physical therapy to support the patient's mobility and strength.
• Ensuring the patient receives training on the safe use of the power-assist wheelchair to maximize independence and safety.
• Regular follow-up to assess the effectiveness of the power-assist wheelchair and make any necessary adjustments, as guided by recommendations for wheelchair prescriptions being based on careful assessment of the patient and the environment in which the wheelchair will be used 1.

From the Research

Patient's Condition and Request

• The patient has been experiencing mobility-related issues that have been progressively worsening since March.
• The patient has been using a standard manual wheelchair to help with weakness and fatigue.
• The patient is now requesting a power chair due to right shoulder pain from pushing the manual chair.
• The patient reports that physical therapy is helping, but the new shoulder brace has not made a significant difference.

Shoulder Pain in Manual Wheelchair Users

• Studies have shown that shoulder pain is prevalent in manual wheelchair users, with a reported prevalence of 39.8% 2.
• The use of manual wheelchairs can lead to high muscular demand on the upper extremities, resulting in shoulder pain and injury 3.
• Exercise programs have been shown to be effective in reducing shoulder pain in manual wheelchair users, with a significant reduction in pain exceeding the minimal detectable change of 5.10 points for the Wheelchair Users' Shoulder Pain Index 4.

Predictors of Shoulder Pain

• Decreased shoulder muscle strength, higher positive shoulder joint work during recovery, and less trunk flexion have been identified as predictors of shoulder pain development in manual wheelchair users 3.
• Relative intra-individual variability has also been found to be a better predictor of shoulder pain than absolute variability 3.

Treatment and Prevention of Shoulder Pain

• Active physiotherapy interventions have been shown to be effective in decreasing shoulder pain and increasing physical function in people with spinal cord injury who use manual wheelchairs 5.
• However, there is a lack of research investigating prevention of shoulder pain and decreased physical function and quality of life 5.
• Resistance and balance exercises have been found to be effective in improving mobility-limiting physical weakness and balance disorders in older adults with mobility limitations 6.