Literature Review On Wheelchair Mobility: Types, Features, And Users Essay.

Types of Wheelchair

Discuss about the Literature Review forn Wheelchair.

Independent mobility increases self-reliance and snatches the scope of educational and vocational opportunities. Besides that, it promotes the feelings of self-reliance by reducing dependence of any person from their family members. In contrast, a person having impairment in functional mobility suffers from aloofness as they decrease their active participation from various social activities that lead to cause stress, isolation, loss of emotions, and fear of negligence (Finlayson and Van Denend 2003).There is an estimation suggesting that around 10 to 15 percent of the total world’s population suffers from disability (WHO 2008, 2011). Among these numbers of disabled persons, ca. 10 percent feels necessity to use wheelchair for their mobility purposes (Sheldon and Jacobs 2006).

Manual form of wheelchairs designed in the traditional way offer mobility for those individuals having physical impairments but less suited for persons possessing both cognitive and physical impairments. The demand of manual wheelchair is more as compared to the wheelchairs driven by power as both physical as well as cognitive skills are necessary for powered wheelchairs that might not present among all individuals. Individuals, who are thought to be incompetent regarding issues like safety and operating powered or manual wheelchairs by their own, generally placed in manual wheelchair and drive by their caregiver.

So in recent days, wheelchair mobility has become a necessity for persons having disability in lower limbs. As a token of example, in the Netherlands among total number of populations ca. 1, 50,000 peoples are using wheel chairs in their day today life (Van Drongelen et al. 2002).One of the most common form of wheelchair, used for the purpose of mobility, is the hand rim wheelchair. The mobility relying on the hand rim wheel chair is considered to be the most inefficient type of locomotion due to its consequence of causing shoulder pain (Alm et al. 2008; de Groot et al. 2013).

The impulsion of a Hand rim wheel chair is a preciously high end repetitive work. Age related issues are intricately related to the usages of upper body arms. The shoulder and the wrist joint are the two barest joints in human body. For making wheel chair user friendly the quality of independence and freedom of moving has to be incorporated. Mobility is an important directive of life which is being followed at the time of its limitation. Mobility can be in a joint manner or may be partially in a daily basis, it is a multilayered concept. Most of the people who rely on wheel chairs for them mobility is not only depend on the health of them, but also on their independencies. It is very important for daily life of any impaired personto make a balance between physical activity, comfort level and the overload. Optimal wheel chair will play a vital role in their life. Ample of mobility devices are present in the market.Likewise, there are two different types of devices: Manual wheel chair and Power assist wheel chair. Manual wheel chairs are light in weight, easy to handle and transport. In comparisons, those chairs that require power to go, creates difficulties for the people who already is in a challenging terrain.Power assisted wheel chairs consume less energy. In case of power assisted wheel chair, it is propelled like manual wheel chair but the moving of the chair is depended on the motors attached with the wheels of the chair. The benefits of Power assisted wheel chair are excessively discussed in literatures. Replacing the wheels of a power assisted wheelchair is very difficult, the weight of the user may affect the impulsion of the wheel chair. Resistance of the rolling of wheel is across the surface is the friction which create at the time of the impulsion. It was noticed in various literature the manual wheel chair impulsion also depended on the effect of total weight, design of the tire, the material composition, resistance power of the chair, alignment of the wheel, type of surface for impulsion.

Types of People Using Wheelchairs

Manual wheelchair is the most common type of wheelchairs which is self propelled and there is not an assistance of any battery or auto propelled system. 

Transport wheelchairs or medical transport where a companion pushes the user of a wheelchair. Most of the wheelchairs have a swing away leg rest and have fixed armrests and side panels Most of the travel wheelchairs are made of durable aluminium.

Tilting wheelchair have a seat back angle which is maintained as the seating system rotates around a sliding or fixed pivot point.  

Tilting wheelchair provides relief on the rear provided by redistribution of the pressure top the back of the user.

Reclining wheelchairs allows a person to recline at angles which are safe and comfortable to them.

The Lightweight Manual Wheelchair is an immense upgrade over the heavy wheelchair causing the conditions to worsen and leads to physical issues. Wheelchairs which are foldable become the norm of the industry benefitting the lighter frame and the lighter equipments and helps the users of the wheelchair in performing their daily activities without the weight of the wheelchair being an issue(Hiremath  and Ding, 2011)..

Bariatric wheelchair reinforces cross braces and other design features to make sure that there is reliable durability in handling the extra support.

Active wheelchairs are easy in manoeuvring and resemble a majority of sports wheelchairs which are out on the market. Active wheelchairs are ideal for sports and other physical activities.

All ultra lightweight wheelchairs have companion handles and the chairs have desk length armrest pads. Wheelchair models have flip back armrests making the transport much easier especially in the trunk of a car or any storage locations (Morrow et al., 2010).

Fixed armrests on a wheelchair is the most common type of armrest available. Flip back as well as removable armrests are used to allow the user of the wheelchair in shifting the component in allowing them in transferring the in and out o the chair easily.  

Attendant propelled chairs are designed being propelled by an attendant by using the handles and the back wheels are without rim and are used as transfer chairs possibly within an airport or a hospital to move a mobility-impaired person when a better alternative or a standard of user chair is unavailable.

A motorized wheelchair powered chair, electric wheelchair or electric powered wheelchair is propelled by means of electric motor rather than manual power. Motorized wheelchairs are useful for those unable to propel a manual wheelchair or may have the requirement in using a wheelchair for distances over terrain which is fatiguing in a manual wheelchair.

Features of a Wheelchair

A rigid frame wheelchair is usually a non folding type with a base of support on which a person sits. Backrest of a chair is folded down and the wheels have a quick release mechanism in enabling easy storage and transportation (Hosseini et al., 2012).

Wheelchairs are necessary for the people having neuromuscular conditions which cause the people to become dependent upon others regarding their daily activities. Wheelchairs help these people to have independence and delay the onset of deformities.

Proper wheelchairs help a person to overcome fatigue and over-exertion harmful to the muscles. Shopping trips helps the user of a wheelchair to continue the daily activities having a wheelchair also prevent a crisis if there is a fracture from the fall. The wheelchair will be required by these people.

People requiring a postural support may be dependent on a wheelchair. They are not able to move independently and often sit for a long period of time. People having neuromuscular conditions do not accept the change to seating. Wheelchair may not be suitable after the delay of its assessment by the time it is provided. Health may deteriorate with the delay in the provision of the wheelchair.

People having neuromuscular conditions have considerable issues from sitting to standing because the difficulty of bearing a weight on a bent knee. Users of wheelchairs push up on the armrests facing forward by the use of wide based stance to face the chair and push up backwards. 

When there is a weakness of the proximal muscles starts causing the user in falling frequently she struggles in rising from the seated position and make small postural changes to help balance when walking over negotiating ramps and kerbs (Sonenblum et al., 2012)..

Locomotion includes the people using the wheelchairs and those walking can only with difficulty use some form of help like sticking and walking frame.

Wheelchairs are the chairs with wheels helping the people to move around. People having impairments and cannot walk are the users of wheelchairs. It has a seat which is supported on the two large wheels attached towards the back of the seat and two small wheels, footrests and a cushion. There are additional features in preventing toppling in assisting the mounting curbs. People who require mobility devices like wheelchairs without having a robust support system so there is a trend of under-reporting.

There are many decisions to be made when prescribing a wheelchair to understand how the decision affects other decisions which are important. Wheels sometimes affect the seat height. Right cushioning and back support are meant to be comfortable for the right posture and seating tolerance is the first step to prescribe a wheelchair (Desroches et al., 2010).. A wheelchair requires being functional in the environment of the user, adaptable to the prognosis of the user, increasing the ability and enabling their participation in the desired activities.

Gorce and Louis (2012) conducted a study for testing the effect of practice in wheelchair, height of the seat, and position of anteroposterior axle based on the propulsion kinematics related to the parameters of upper limb joints like flexion-extension of the shoulder, axial rotation and abduction-adduction, flexion-extension of the elbow and wrist, pro-supination angles of the forearm (measured in degrees), and radioulnar deviation. Besides that, the same study also focused on the process of using hand rim wheelchairs, average propulsion speed, and trimming of movement. The parameters considered for the hand rim usage included hand-rim angles which were analysed by the contact of the hand rim, vertex and release and amplitude over propulsion. Whereas timing parameters for movement were cycle, momentum and recovery times (measured in second), and percentage of propulsion required for a complete cycle. Their study revealed that there was a significant difference in propulsion speed like experts possess a bit higher speed as compared to the beginners (Gorce and Louis 2012). Result of their study supported Kotajarvi et al. (2004) regarding the difference in the pattern of upper limbs among these two groups. The crucial findings of their research supported various previous studies (Shimada et al. 1998; Boninger et al. 2002) regarding that experts used mostly semi-circular over propulsion patterns, but all the beginners relied on an arcing pattern. Two phasesof propulsion pattern were observed among the experts like a traction that was immediately followed by pushingthe wheel, whereas beginners preferred to use only push to the handrim.Experts were found to be using median seat height for better suitability of the hand rim access, but lower seat height were noticed to be much effective to the beginners for the said purposes. Concordant with Wei et al. (2003), their study supported regarding decrease of propulsion time and increase of recovery time among the beginners, but contradicted for the case of the experts as they noticed significant difference only in the propulsion time. Seat height was found to be related with increasing movement frequency. They showed that activations of the higher muscle are correlated with the anterior axle positions that could easily be correlated with the higher risk leading to several musculoskeletal disorders. So, there should have to be a correlation between manageability of wheelchair, efficiency and several factors related to joints disability (viz. higher muscle recruitments and limit proximity of the joint) and the less traumatic axle position.

The effect of wheel mobility for movement of any wheelchair is considered to be one of the fundamental issue when the health of any impaired person is concerned (Dallmeijeret al. 2005). Motion extremes, repetitive increase of loads, and muscle load in a disorganised manner during propulsion of wheelchair causes several kinds of injuries to the upper-limbs (Cooper et al. 2001). So pain, one of the crucial factors in functioning of our day-to-day life, is an intricate problem generally faced by any wheelchair user.

One of the driving forces in resisting the propulsion of wheelchair is none other than that of the rolling resistance which exerts its pressure upon the upper limbs. So there was a craze among researchers to investigate the necessary requirements like expenditure of energy, propulsion efficiency, and the variances in rolling resistance during power assisted and manual propulsion by the user. For the said purpose, Pavlidou et al. (2015) conducted a study that was solely based on difference in tire pressure and different levels of motor assistance. Drag force, expenditure of energy and efficiency of propulsion were also measured in that study in a treadmill under several experimental conditions. Results of their study revealed significant higher drag force level in half inflation condition as compared to more or full inflation condition and the value of drag force in case of power assisted wheelchair was significantly higher when compared to that of the manually driven one. In a case when the propulsion efficiency and the required energy expenses by the user is concerned, the acclimatization of extra-power-assisted wheelchair appeared to be significantly higher than that of the manual and conventional power-assisted wheelchairs. So Pavlidou et al. (2015) concluded that depending on the supplied motor assistance, the habituation of wheelchair driven by power was more effective because of consuming less energy input by the user.

In order to provide ambulation for increased number of people wheeled mobility is essential. According to Morgan et al., (2015) the enhancement in the wheelchair skills results in making the wheelchair user-friendly. As a result of this user-friendly nature of wheel-chairs the mobility of wheelchair also elevates that contributes to the increased mobility freedom, independence of the patient.

In this context the aspect of wheeling and (in) activity is also required to be discussed. About two decades ago, the significance of lifestyle with physically active living was recognized. The recognition was done with the help of bodies like American College of Sports Medicine. According to Aksay, (2014) had identified, the health associated mobility problem of an individual completely dependent on wheelchair.  On the basis of this, the contribution of regular active life in terms of overall wellbeing and health of an individual can be recognized. On the basis of the international scenario, it can also be noticed that, sedentary lifestyle acts as the basis for various chronic disease like diabetes (type 2), cardiovascular diseases.

Arm work associated with wheelchair puts strain on the physical condition, particularly for those who are not well-trained.  Upper body musculoskeletal overuse is a mentionable long-term health-issue associated with individuals dependent on wheelchair. In this reference, it has been proposed by Deems-Dluhy et al., (2016) that a minimum of activity for 1 hour associated with hand rim wheelchair results in around 1800 bi-manual pushes. An estimated 40 kg compression force is generated in the shoulder with every push as a reaction to it.

Over the last decades there has been significant development in the manual wheelchair technology due to the technological enhancement. However, the feature of hand rim wheelchair has not really evolved as it can be seen from the scenario of the western world. The major development in the manual wheelchair technology can be seen from the replacement of wheelchair consisting of sling-seat chromium plate that exists in the period of 1950s to function-specific, lightweight modern designed wheelchair (Shyu et al., 2010). Though the development was mainly the contribution of conducted researchers, yet sports practice also played a role in this aspect.  However, it is mentionable here that, hand rim wheelchair has become functional, versatile device in reference to the aspect of mobility.   

The aspect of rolling resistance is vastly impacted by the wheelchair technology, design and its associated aspects. As a result of this studying the various wheelchairs and the characteristic of tire is required. It can be established with the help of the fact that, over the years, the evolutions to other materials like titanium, carbon fiber from original steel establishes the fact. The reason being, as a result of this development, the strength, stability, endurance and mass of the wheelchair also increase.  Other than that, on aspects like energy cost, stability and versatility of the wheelchair is largely impacted by vehicle mechanics (Ishihara et al., 2005).  In order for a wheelchair to be effective emphasis is required to be given on both mass and construction of a wheelchair. In this context it is mentionable here that as compared to the wheelchair mass, individual mass plays a greater role. In reference to sports practice and rehabilitation, body weight management plays a crucial role.   

In terms of sports performance, individual turning associated with wheelchair-user interface is significant. In this aspect, to individual physical characteristics, the wheelchair is fully fitted. In wheelchair racing, or rehabilitation, rim diameter variation is particularly used, which is a form of gearing. In this context, Shyu, Chang and Shyu, (2010), clearly stated the impact of gearing on mechanical efficiency in the context of rim wheelchair propulsion. The techniques and required energy is affected by hand’s linear velocity of the hands in the phase of push. In accordance to Richter, a specific impact compliance level can be observed in the context of hand rim’s compliance role in the mechanical impact on hand and its reduced impact.

As a solution to overcome the hand rim wheelchair’s use alternative propulsion mechanism is considered as a solution. In this context it has been opined by MacDonald et al., (2009) that other than hand rim forced wheelchairs, there that alternative beneficial ways in the context of physical cost and energy strain.  Tricycle propelled level is an instance to this, particularly crank wheelchairs. It highlights upon its essential role in extreme environmental conditions particularly in several non-western countries. It provides with higher velocity over a longer period of time which also requires less physical strain.  The reason being the fact that with the help of cranks and levers allows the use of extensor and flexor muscles that results in less strain where as in hand rim propulsion, as a result of discontinuous motion active work is not allowed.

Janssen et al., (2008) has put forward the fact that in context to restoration and reactivation of mobility for the Spinal Cord Immured (SCI) and other indivuals who are suffering from impairments in their lower limbs, there have been several developments and evolution in the bio-technical research to ensure lower limb functioning and walking on the part of the impaired individuals. Thus these developments in technology can be termed as assistive technology and it can be illustrated with the help of the examples like robotics in activities of daily living (ADL) together with upper extremity neuroprostheses that is based upon electrical simulation for the individuals who are suffering from tetraplegia. So these technologies prove to be beneficial and assist in restoring the normal functionality of the SCI and other individuals.

The studies conducted by van Drongelen et al., (2006) has also led to the fact that functional and neuromuscular functional stimulation (ES) is not limited only to the upper body exercise and in addition to these, cycling and treadmill has also provided various clinical benefits.  

The study conducted by Jones et al., (2012), was aimed at analyzing the effect of power wheelchairs on the children who are suffering from severe motor impairments and also analyzed the developments that took place in the cognitive and the psychological skills of the children. In order to conduct the study, the families of the children were provided with training guidelines whereas the children under study were facilitated with power wheelchairs that were characterized with customized seating. The study revealed the fact that there have been significant developments among the children with motor limitations through the use of the power mobility. In addition it was also observed that the time required by the children suffering from motor impairments to become proficient was around 12 to 42 weeks and thus Jones concluded that it would prove to be beneficial on the part of the children to become quickly efficient in using the powered wheelchair if more intense training is provided in a controlled and structured manner.

Moreover, as per the responsive partner theory put forward by Durkin, (2009), the mobility teacher i.e. the trainer should not play the role of providing training to the children but he would also be responsible for setting up a learning environment that would be capable of meeting the individual needs of the children suffering from severe motor impairments and the environment and the device should also be capable of prodding the children with the opportunity to play. In this context it can be said that, the individuals or the learners who are suffering from motor impairments demand seating that is customized to meet the specific needs of the impaired individuals (Durkin, 2006). But, it becomes difficult on the part of the trainer or the therapist to design customized seating for the impaired individuals in case of power wheelchair since it might be the case that the wheelchair can be used for several individuals.                 

Thus taking into consideration the above aspects, the concept of Turtle Trainer was developed and it was presented at the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA) conference. This concept was developed in order to convert the manual wheelchair into a power wheelchair and the development was made in order enhance the ability of the individuals to make an efficient use of the power mobility. The device that was developed was described by Bresler, (1990) as motorized cart that has been characterized with wheelchair tied owns and it also consists of a ramp that facilitates in the loading and unloading of a manual wheelchair.      

Since then, there have been several developments in the wheelchair and it has been characterized with several types of controllers that include the push button, joystick, sip and puff controllers, head array and push button and these controllers are widely used in the wheelchairs for individuals suffering from different type of injuries (Livingstone, 2010). However, these controllers also suffers from limitations like it has been generally accepted that except the sip and puff controller, the other controllers assume the patient to be characterized with reliable mobility in their body.

Again, the advancements that have taken place in the microprocessors have led to several innovations in context to control interfaces of the power wheelchair together with several areas of the assistive technology. Thus in addition to the common interfaces that include the chin and head controls, sip and puff controls, the power wheelchairs have been characterized with various control schemes that include eye gazing systems and the tongue touch pads (Hildebrand et al., 2014).   

Thus looking at the developments that have taken place in the present day in power wheelchairs, there still exists some shortcomings like the individuals suffering from multiple and severe disabilities may find it difficult to steer the power wheelchair in a particular setting that has limited space.  

Moreover, with rapid advancements in technology, segway technology emerged as a new cutting edge that is characterized with key spawning marvelous concepts that includes the iBot wheelchair possessing the ability of climbing the stairs and it can also raise the individual to a certain standard height that is equal to height of the individual when he is standing (Bayer et al., 2007). On the other hand, thought controlled electric wheelchairs have also emerged that has been mapped with the human brain neurons electrical activity and this device has been interpreted and programmed with the help of the complex algorithms of mathematics. Again, robotics cannot be considered to be cutting edge technology; however design of the robotic devices has made a significant influence the design of the wheelchairs.

Thus from the above discussions, it can be concluded that several developments have taken place in technology and this has changed the face of the wheelchairs that used to be operated by the individuals manually. The developments also had made it easy on the part of the individuals suffering from severe motor disability to mobilize and carry out their day to day activities in a much efficient manner.    

According to concept of World Health Organization, in world population about 10 % to 15% of people are disabled and they require wheelchair. Mobility assistance is accessed approximately 20 million in the world. According to Bray et al. 2014, there is inadequate wheelchair mobility service which is needed to be organized for disabled people. For assistive mobility technology because of poverty level, disabled people are deprived from buying the wheelchairs which are cost effective. As per United Nations, disabled people are assisted with mobile technology, so that they do not face any trouble in walking.

In worldwide about 5% of children is disabled, each people needs to view on economic impact. There are various kinds of wheel chair. There are children who is patient of cerebral palsy, they need specialised seating and or them those wheelchairs are needed to be arranged which has mobility and which are assisted with technology. There are some policies which are adopted by World Health Organization and United Kingdom and as per those policies; exclusion limit should be handled by the appropriate wheel chair intervention method.

It is estimated that, there are 770,000 children and young people who are under 16 years’ old lives in UK. According to NHS, it is necessary that, evidence and effectiveness are evaluated with wheelchair intervention procedures. Range of positive impacts is needed to be developed with global understanding. Specific role is played by health economists to develop the wheelchair services. According to Brey et al, 2014 in BMC Heath Service Research mentioned about the social theories with positive approach in disability management are needed to be treated with conceptual framework from the evidence which synthesize the diverse evidence.

There are certain aims and objectives which explores the current effectiveness of the perspectives of service users. For interpretation, searching and management some aims and objectives are as follows:

• Cost effectiveness of wheel chairs should be reasonable for disabled people.
• NPO publication and UK policy is needed to be explored with current implications and guidelines.
• Matching outcomes and aspired existing policy is needed to be calculated with aspired objectives.

There is an initial scope of review which is demonstrated by multi-faced nature which is demonstrated for intervention of wheelchair. The University of York Centre has followed review method with various principles and extracting data conducting various researches. According to Thomas and Harden (2008) narrative summary is drawn with synthesize evidence adopted with mixed method which is conducted on April 2012. According to University of York Centre, review is followed on Research and Dissemination by extracting data which shows the intervention method of wheelchair technology. For publication bias Grey has translated the inclusion of bibliographic program. In academic database NEPO literature and policy is not available basing the academic database.

Screening is based on three stages which are identified with exclusion and inclusion criteria. The screening process is based on the search engines followed by NFPO website for saturation of basic information. There are various types of evidence synthesis:

• Intervention: Effectiveness and outcomes with all quantitative studies is the evidence which is based on relevant interventions.
• Opinion evidence: Explored perspective is viewed with relevant intervention which is related to the effective evidence which is related to the intervention.
• NFPO Literature and Policy: Clinical guidance literature with all policy is related to the screening process.
• Economic Evidence: Economic cost effectiveness is related to this evidence. 

For developing framework, overarching synthesis was found from the program theory which is based on evidence and its pathways and current services with highlighted gaps are found by this framework.

Opinion evidence and intervention has shown in the provision of wheelchair. According to Benedict 1999, Family involvement is required to be provided by PWC for accessing and transporting the cost effectiveness of the person who needs wheelchair (Wiart L, et al. 2004) According to Guerette, 2008, there are several areas which is needed future development which is followed by streaming management, translation framework and procurement strategies which is needed to be developed by producing several higher quality wheelchair which is needed servicing and other techniques should also be followed with it.

According to Department of health, or lifestyle oriented focus and social independence effect, promotion of independence in measurable outcome is needed to be followed with programme theory in optimal wheelchair service provision.

Research has focussed on health economic methods exploring the service quality of the users in health department which follows the QALYs intervention method and values of transparent ideas adopted by higher quality techniques of solving the method of interventions followed by various techniques and ideas should be adopted with various perspectives and methods which is acquired to bring benefit in changing the intervention of health and social care methods.

According to Jones et al, 2012 established some basic changes in RCT which is related with intervention in studies for children, there is Health Utilities Index and in that index health measures are needed to be followed with various aspects and rules for determining the holistic effectiveness. Data is generated with efficient equitable methods. There is distinct impact which is followed in wheelchair services and that is needed to be promoted with inclusion and independence. Various strategies and interventions are needed to be adopted with various techniques and data generation processed with current implications.

Varied benefits are found with social inclusion and development method for facilitating the intervention techniques of wheel chair. Various people are affected with several diseases followed with collaboration and cost effective method. All these strategies are made for the disabled people who are inefficient and needs help for walking and moving in different places. QALYs research and techniques has been followed through which the change is developed that how should development process be synthesized and followed with various ways adopted for bringing change by screening and designed method for implications and development in manufacturing and providing wheelchairs. 

These guidelines are inputs and developments given by EnableNSW (NSW Department of Health) and LTCSA (Support Authority) are made to assist physiotherapists to advise regarding wheelchairs with seats also known as mobility scooters for people suffering from mental and physical injury. These ideas were made after opinions were taken from panels of therapists who are specialised in neurotic and spine cord related injuries. This panel consists of members of NSW Health and NSW Lifetime Care and Support Authority. According to World Health Organisation, there is a structure which is used in the guidelines which derives information from a health model of biological, psychological and social nature. They are related to the human rights issue and health scenarios described in the Convention of the Rights of Persons with Disability (CRPD).

The reason for making the guidelines was to aid people with physical and mental disabilities. They intend to solve problems existing due to poorly made wheelchairs. They have detrimental effects on the possible activities and life related goals and health situation of the affected person. By careful usage of research material, the guidelines provide the most appropriate recommendations for advising the best wheelchair of a person.

The guidelines were made for the following individuals to use-

• Professional physiotherapists and therapists who give prescription for wheelchairs for patients with brain and spinal cord injury.
• Rehabilitation engineers who are equipped with the special knowledge regarding advice of wheelchairs. 

The recommendations have been made on the basis of evidentiary value. These evidences have been ranked on the basis of well tested criteria. The guidelines were created by regular updating applicable research literature which were published during the year of 1999 and the month of August, 2010. From the research literature, the material that was derived was checked for authenticity and meticulously analysed by two organisations. These analytical data was derived from Levels for the strength of evidence (levels I-IV) of the National Health and Medical Research Council (NHMRC) and the method of ranking of recommendations given for the guidelines (Hillier et al., 2011). The research literature contained studies and reviews of the experiences and viewpoints of the users of wheelchairs. Various cases were studied on quality basis in order to make the evidentiary value of the research more strong. The material was hence forwarded to the panel responsible for formulating the guidelines.

The design of the research literature contained-

• Research on statistics which were analysed by the NHMRC’s study on the list of evidences for studies regarding intervention, the divided PEDro scale was put into use (Pedro.org.au, 2016).
• The research on quality of the wheelchairs were analysed on the basis of the qualitative appraisal checklist of the McMaster’s University.
• The lone research on cases were analysed on the basis of Single Case Experimental Design (SCED) scale (L Tate et al., 2008). 

By giving access to a wheelchair, a complicated therapy based help is done with the intention of bettering an individual’s functioning. There is no formula involved in creation and advising regarding a wheelchair. It is more of a stepwise growth process. Well aligned and assembled wheelchairs help the affected individual by reducing the gravity of hisher disability. By employing a very economic solution, a decent match can be derived and might result in immense benefits.

The guidelines can be found in-

• The World Health Organization International Classification of Functioning, Disability and Health (ICF)- Under this structure it is shown how a person adjusts and functions on the biological, psychological and social aspects of health. The structure draws a link between an individual’s physical aspects like injury, disability or illness and facets of the outer environment like social behaviour, building related hindrances as well as legal and society based lacunae. It also includes facets of personal nature like age, gender, adjusting method, previous and present experiences and character.
• The United Nations Convention on the Rights of Persons with Disabilities (CRPD) - This is a committee or unit which deals with human rights. They deal on the principle that people who have disorders are equipped with rights and are capable of entering into decisions and conclusions. They also have the right to be helped and assisted for making such decisions. They have all rights to be regular and active citizens of the society as every person are. The organisation or unit stresses on the thought that the affected person must be fully involved and should be the plinth of the therapeutic solution. According to the articles 19, 20 and 26 of the CRPD, the organisation gives impetus to supportive apparatus which helps in mobilizing the individual so that he/she can participate in the social community. 

While approaching towards solution by therapeutic methods, all therapists should adhere to individual and professional ethics (Mortenson et al., 2008). While introducing the therapy to the patient, the practitioner must keep in mind various principles of ethics. According to S. Taylor (2005), these ethics can be applied in matters of taking decision (Taylor, 2005). Certain principles can be like-

• Respecting the individuality and autonomous character of the client. This involves their choice, personality, independence of will and secrecy kept for the client and his/her helping attendant.
• The psychotherapist or the therapist is supposed to act or perform which is supposed to be consonance with the good of others and should be in an effort to bring wellbeing of the client.
• By ensuring care and diligent approach, the therapist should try to curb problems and harm to the client.
• The effort of the therapist should be justifiable and fair in nature. 

Hence from the above discussions it can be derived that United Nations has devised a programme or unit which takes care of disabled and their rights to take decisions. There are certain guidelines prepared for the purpose of providing therapeutic solutions and interventions to people with severe mental traumatic conditions and with spinal cord injuries. These guidelines are based on well researched literature prepared on careful evidencing.

As stated by Sabol, and Haley, (2006), the most common use of Reclining wheelchairs is found in Taiwan for movement of patients impacted by stroke. The statistics report related with Reclining wheelchairs state that almost 66.4% of wheelchair prescription at the technology centre was accounted from 2007 to 2009 for this specialized wheelchair. The review of literatures further stated that 58.5% of reclining wheelchair was used by patient suffering from stroke. On reviewing the features of reclining wheelchair it is observed that generally its light weight, not expensive in nature, foldable thereby making it easy to carry and available commercially. In addition the functional attribute related with reclining wheelchair is the trunk support provided by the apparatus to the patient suffering from stroke with special focus on hemiplegia. It also assist elderly patient suffering from stroke who exhibit poor sitting balance and tolerance issue and by reducing the sitting pressure and managing pressure sores.

Nevertheless there arises area of concern with regard to the use of reclining wheelchair by patients suffering from stroke. According to Sackley, (2008), the body of the patient tends to slide forward most often in the wheelchair as the patient resume the sitting position from reclined posture. This sliding of body makes for sacral sitting position with end result of enhanced stress of sacral shear. This is how the patient is predisposed to sacral pressure sore as stated in the review of literature. This demands that the care givers handling the patient needs to reposition frequently to avoid pressure sore. As evident from the review of literature a novel ergonomic V-Seat was developed to avoid the problem of forward sliding of the patient and avoiding the pressure sores. The seat is designed to sinks upto 20 degrees at a downward angle at the backseat while reclining of backseat upto 160 degrees is supported. The effectiveness of this V-Seat reclining wheelchair for patient suffering from stroke and hemiplegia is yet to be established. It is exhibited below 

The literature review explained the effects of investigation of both the conventional seats and V-Shaped used in reclining wheelchair with regard to forward sliding and problem of sitting pressure for patient suffering from stroke and  identified with flaccid hemiplegia and elders with normal body. The hypothesis taken was 1) elders with normal body and patient with flaccid hemiplegic are subjected to varied mechanism in the context of forward sliding and interface pressure in the process of making use of V-Shaped seats and 2) As told by Sackley , (2008), the reclining wheelchair fitted with V-Seat can opt for reduction of forward sliding and sitting pressure with regard to the patient suffering from stroke with flaccid hemiplegia.

As opined by Mac et al., (2009), the reclining wheelchair fitted V-shaped seats can lead to reduction in the forward sliding and sacral pressure at the peak for patients suffering from stroke with flaccid hemiplegia confronting the issue of forward sliding often along with sacral pressure in the process of using reclining wheelchair compared to the elders with normal body. Thus reclining wheelchair fitted with V-Shaped seats are designed to serve the purpose.

As told by Sauret (2013), people suffering from mobility impairment and using wheelchair in most cases, the impact of mobility related with wheelchair are of primary concern, not from the perspective of health factor alone, but also from the perspective of quality of life and the sense of independence. The review of literature further identifies that high loads on repetitive basis, motion extremes and muscle load disproportion related with process of wheelchair propulsion as the reason behind the upper limbs injuries chronically. The patient using wheelchair encounter pain in the upper limbs and it has critical implication in the daily activities of the patient. This makes it significant to strike a balance between physical activities in sufficient manner, utmost participation, comfort level and overload basis. There is a significant role that can be served by the wheelchair choice optimally.

In the market there are wide ranges of mobility service available. The review of literature focus on manual wheelchair and power assisted wheelchair (PAW) based on user input and promoting the physical activity of the patient. As stated by Kotajarvi, (2004), the wheelchair with manual operation is generally lightweight, manipulated easily and transport without hassle. The limitation of manual wheelchair is related with the manual propulsion where it is inefficient highly (with mechanical efficiency depicted at 2% to 10% low value range). It demands power inputs and if the individual is less capable then it not possible like in the case of challenging terrain. On the other the review of literature state that the power assisted wheelchair are an alternative that demand less energy. As opined by Kotajarvi, (2004), it is propelled by wheelchair that is supported by motor additionally and this integration into the wheels enables propulsion at different level. Further the advantage of PAW has direct implication on the two factors and they are different kinds of PAW available and impairment level of the patient. The literature establishes the benefits of propulsion assisted by power. The fact that the different kinds of PAW available commercially are 20 kg heavier compared ot the manual wheelchair approximately. This makes the removal and replacement of wheels very difficult thereby establishing the fact that transport independently not easy. In addition as observed in the review of literature that weight increase also impact the rolling resistance.

As told by Cowan, (2009), the major force that oppose the tire motion as it rolls across the surface is the rolling resistance. The inelastic deformation of the material related with tire and/or the surface is identified as the cause for this. There are many literature on manual wheelchair and explain the laden effects  and total weight, design of the tire and inflation pressure, composition of material, resistance internally, alignment of the wheel and type of surface related with propulsion. According to Van et al., there is direct implication of physical stress and energy cost on the floor surface and material. The rolling resistance increase directly leads to increased expenditure on energy and tires deflated are related with rolling resistance at higher level. 

References

Alm M, Saraste H, Norrbrink C., (2008) Shoulder pain in persons with thoracicspinal cord injury: prevalence and characteristics. J Rehabil Med;40:277–83.

Boninger, M.L., Souza, A.L., Cooper, R.A., Fitzgerald, S.G., Koontz, A.M., Fay, B.T., (2002). Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Am. J. Phys. Med. Rehabil. 83, 718–723.

Cooper RA, Fitzgerald SG, Boninger ML, Prins K, Rentschler AJ, Arva J. Evalua-tion of a pushrim-activated, power-assisted wheelchair. Arch Phys Med Rehabil 2001; 82(5): 702–708.

Dallmeijer AJ, Kilkens OJE, Post MWM, deGroot S, Angenot ELD, van Asbeck FWA, (2005)., Hand-rim wheelchair propulsion capacity during rehabilitation of persons with spinal cord injury. J Rehabil Res Dev; 42(3): 55–64.

de Groot S, Vegter R.J.K., van der Woude L.H.V. 2013. Effect of wheelchair mass, tire type and tire pressure on physicalstrain and wheelchair propulsion technique.Medical Engineering & Physics 35: 1476– 1482.

Finlayson M, Van Denend T., (2003), Experiencing the loss of mobility: perspectives of older adults with MS. DisabilRehabil.; 25(20): 1168-1180.

Gorce, P., Louis, N. (2012). Wheelchair propulsion kinematics in beginners and expert users: Influence of wheelchair settings. Clinical Biomechanics 27: 7-15.

Kotajarvi, B.R., Sabick, M.B., An, K.N., Zhao, K.D., Kaufman, K.R., Basford, J.R., (2004). The effect of seat position on wheelchair propulsion biomechanics. J. Rehabil. Res. Dev. 41, 403–414.

PavlidouE, KloostermanM.G.M., BuurkeJ.H., RietmanJ.S., JanssenT.W.J. 2015. Rolling resistance and propulsion efficiency of manual and power-assisted wheelchairs. Medical Engineering and Physics 37: 1105–1110.

Sheldon S, Jacobs NA (2006). Report of a Consensus Conference on Wheelchairs for Developing Countries, Bangalore, India. Copenhagen: International Society for Prosthetics and Orthotics; 2007

Shimada, S.D., Robertson, R.N., Bonninger, M.L., Cooper, R.A., (1998). Kinematic characterization of wheelchair propulsion. J. Rehabil. Res. Dev. 35, 210–218.

Van Drongelen A, Roszek B, Hilbers-Modderman E, Kallewaard M, WassenaarC., (2002). Wheelchair incidents. Bilthoven: RIVM.

Wei, S.H., Huang, S., Jiang, C.J., Chiu, J.C., (2003). Wrist kinematic characterization of wheelchair propulsion in various seating positions: implication to wrist pain. Clin. Biomech. 18, S46–S52.

World Health Organisation, (2008): Concept Note. World Report on Disability and Rehabilitation. Geneva, World Health Organization. Geneva: World Health Organization;

World Health Organization (2011): World Report on Disability. Geneva: World Health Organization.

Jones, M. A., McEwen, I. R., & Neas, B. R. (2012). Effects of power wheelchairs on the development and function of young children with severe motor impairments. Pediatric Physical Therapy : The Official Publication of the Section on Pediatrics of the American Physical Therapy Association, 24(2), 131-40; discussion 140. doi:10.1097/PEP.0b013e31824c5fdc

Bresler, M. I. (1990). Turtle trainer: A way to evaluate power mobility readiness. Proceedings of the 13th Annual RESNA Conference, 399-400.

Durkin, J. (2006). Developing powered mobility with children who have multiple and complex disabilities: moving forward (Doctoral dissertation), University of Brighton.

Durkin, J. (2009). Discovering powered mobility skills with children: 'Responsive partners' in learning. International Journal of Therapy and Rehabilitation, 16(6), 331.

Livingstone, R. (2010). A critical review of powered mobility assessment and training for children. Disability & Rehabilitation: Assistive Technology, 5(6), 392-400.

Hildebrand, Stewart James, (2014). "Development of a Control System for a Power Wheelchair Trainer". Masters Theses. Paper 717.

Bayer, D., Springsteen J. and Nash, R., (2007). "A next generation intelligent wheelchair control system," in Technology and Persons with Disabilities, pp. 41-5.

Janssen TW, van Oers CA, Rozendaal EP, Willemsen EM, Hollander AP, van der Woude LH. (2008). Changes in physical strain and physical capacity in men with spinal cord injuries. Med Sci Sports Exerc;28:551–9

van Drongelen S, de Groot S, Veeger HE, Angenot EL, Dallmeijer AJ, Post MW, (2006). Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury.

Desroches, G., Dumas, R., Pradon, D., Vaslin, P., Lepoutre, F.X. and Chèze, L., (2010). Upper limb joint dynamics during manual wheelchair propulsion. Clinical Biomechanics, 25(4), pp.299-306.

Hiremath, S.V. and Ding, D., (2011). Evaluation of activity monitors in manual wheelchair users with paraplegia. The journal of spinal cord medicine, 34(1), pp.110-117.

Hosseini, S.M., Oyster, M.L., Kirby, R.L., Harrington, A.L. and Boninger, M.L., (2012). Manual wheelchair skills capacity predicts quality of life and community integration in persons with spinal cord injury. Archives of physical medicine and rehabilitation, 93(12), pp.2237-2243.

Morrow, M.M., Hurd, W.J., Kaufman, K.R. and An, K.N., (2010). Shoulder demands in manual wheelchair users across a spectrum of activities. Journal of Electromyography and Kinesiology, 20(1), pp.61-67.

Sonenblum, S.E., Sprigle, S. and Lopez, R.A., (2012). Manual wheelchair use: bouts of mobility in everyday life. Rehabilitation research and practice.

Bray, N., Noyes, J., Edwards, R. and Harris, N. (2014). Wheelchair interventions, services and provision for disabled children: a mixed-method systematic review and conceptual framework. BMC Health Services Research, 14(1).

Guerette P, Furumasu J, Tefft D (2008): The Impact of Early Powered Mobility on Young children’s Play and Psychosocial Skills. In Proceedings of 24th International Seating Symposium, March 6–8, 2008; Vancouver.2008:160–165

Jones MA, McEwan IR, Neas BR, 2012: Effects of Power Wheelchairs on the development and function of young children with severe motor impairment. Pediatr Phys Ther, 24(2):131–140

Thomas J, Harden A, (2008). Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol , 8:45

Wiart L, Darrah J, Hollis V, Cook A, May L, (2004): Mothers’ perceptions of their children’s use of powered mobility. Phys Occup Ther Pediatr, 24(4):3-21.

Hillier, S., Grimmer-Somers, K., Merlin, T., Middleton, P., Salisbury, J., Tooher, R. and Weston, A., 2011. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC medical research methodology, 11(1), p.1.

L Tate, R., Mcdonald, S., Perdices, M., Togher, L., Schultz, R. and Savage, S., 2008. Rating the methodological quality of single-subject designs and n-of-1 trials: Introducing the Single-Case Experimental Design (SCED) Scale. Neuropsychological Rehabilitation, 18(4), pp.385-401.

Mortenson, W.B. and Miller, W.C., 2008. The wheelchair procurement process: Perspectives of clients and prescribers. Canadian Journal of Occupational Therapy, 75(3), pp.167-175.

Pedro.org.au. (2016). PEDro scale (English). [online] Available at: https://www.pedro.org.au/english/downloads/pedro-scale/ [Accessed 27 Sep. 2016].

Taylor, S.M., 2005. Ethical principles involved in wheeled mobility decisions. International Journal of MS Care, 7(3), pp.107-110.

Sabol, T.P. and Haley, E.S., 2006. Wheelchair evaluation for the older adult. Clinics in geriatric medicine, 22(2), pp.355-375.

Sackley, C., Brittle, N., Patel, S., Ellins, J., Scott, M., Wright, C. and Dewey, M.E., 2008. The prevalence of joint contractures, pressure sores, painful shoulder, other pain, falls, and depression in the year after a severely disabling stroke. Stroke, 39(12), pp.3329-3334.

MacDonald, B., Kirby, R.L., Smith, C., MacLeod, D.A. and Webber, A., 2009. Sitting pressure in the tilted position: manual tilt-in-space wheelchair vs. manual wheelchair with a new rear antitip device. American Journal of Physical Medicine & Rehabilitation, 88(1), pp.61-65.

Sauret, C., Vaslin, P., Lavaste, F., de Saint Remy, N. and Cid, M., 2013. Effects of user's actions on rolling resistance and wheelchair stability during handrim wheelchair propulsion in the field. Medical engineering & physics, 35(3), pp.289-297.

Kotajarvi, B.R., Sabick, M.B., An, K.N. and Zhao, K.D., 2004. The effect of seat position on wheelchair propulsion biomechanics. Journal of rehabilitation research and development, 41(3B), p.403.

Cowan, R.E., Nash, M.S., Collinger, J.L., Koontz, A.M. and Boninger, M.L., 2009. Impact of surface type, wheelchair weight, and axle position on wheelchair propulsion by novice older adults. Archives of physical medicine and rehabilitation, 90(7), pp.1076-1083.

Aksay, E. (2014). The Effects of Using Active Wheelchair (AWC) and Standard Wheelchair (SWC) on Physical Performance -Choosing Appropriate Wheelchair (WC)-. International journal of Science Culture and Sport, 2(7), pp.49-49.

Deems-Dluhy, S., Jayaraman, C., Green, S., Albert, M. and Jayaraman, A. (2016). Evaluating the functionality and usability of two novel wheelchair anti-rollback devices for ramp ascent in manual wheelchair users with spinal cord injury. PM&R.

Ishihara, S., Ishihara, K., Nagamachi, M. and Motoyama, Y. (2005). Head displacements during manual wheelchair propulsion on different floorings. Gerontechnology, 3(4).

MacDonald, B., Kirby, R., Smith, C., MacLeod, D. and Webber, A. (2009). Sitting Pressure in the Tilted Position. American Journal of Physical Medicine & Rehabilitation, 88(1), pp.61-65.

Morgan, K., Engsberg, J. and Gray, D. (2015). Important wheelchair skills for new manual wheelchair users: health care professional and wheelchair user perspectives. Disability and Rehabilitation: Assistive Technology, pp.1-11.

Shyu, J., Chang, T. and Shyu, Y. (2010). A Kinematic Model Used to Customize Design of Manual Wheelchair. KEM, 450, pp.5-8.