Activity performance in everyday life
Listed below are different examples of behavior. The list is to inspire you in considering if the wheelchair
user is at risk of any physical injury – including pressure and tissue injuries – corresponding to the way the
wheelchair is used or the way it is supposed to be used during activity performance. These examples are
from my own experiences during many years of practice in this field.
I can highly recommend to you to try out the activity with your own body by using some sliding material to
make sure that an activity performance needs rethinking or redesigning. Sitting on a sliding material
performing different activities will help you to point out the specific problems in not being stable and
sufficiently pressure distributed in a seated position. If you do so with your wheelchair user (be careful!)
you will create the motivation to think differently as well – the basis of any change of behavior.
Taking the ADL-taxonomy1 as a starting point you might attempt to point out RISKBEHAVIOR in connection
with e.g.:
 Meals
If an anterior tilt in space is used – (meaning beyond horizontal) – to avoid reaching the table with
knees underneath when dining, the behavior is very risky.
If the recline function is used forward in order to press the wheelchair user forward to get a better
truncus-support or perhaps a closer table contact the behavior is very risky.
You must definitely create alternatives to make sure, that the wheelchair user can eat without
these apparently attractive functions, as they will disturb stability and create shear in the tissue
during use as well as afterwards.
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Transfers
If the wheelchair back, footrests, sling, buttocks, or clothes need to be adjusted or corrected after
”landing ”on the wheelchair seat the behavior is very risky, because every correction implies a risk
of losing the necessary stable and continued contact with the wheelchair corresponding to the SIPS
(spina Illiaca posterior superior).
If the wheelchair user is practicing a “low transfer” to “take a seat” it is important that the user is
gaining a stable and continued contact between the chair and the 3 basic support points – SIPS and
the two Tuber Ischii, and that the wheelchair user is able to lift himself 100% up as well. It is
necessary to be very critical about this, as a wheelchair user with many years of experience doing
this may be reluctant to change practice though he might permanently or just temporarily be
weaker than he used to be.
ADL-taxonomy http://www.diva-portal.org/smash/get/diva2:318271/FULLTEXT01.pdf
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Try to find all sorts of risky procedures in connection with transfers – meaning procedures that can
lead to shear and loss of stability immediately and over time.
It is of great importance that the wheelchair user gains and is able to keep a seated position of high
quality. If the wheelchair user glides forward on the seat during the day or immediately during or
after a specific transfer, or if the upper body collapses immediately or during the day - the
wheelchair user is at high risk of caching physical injuries in the seated position. This is an
expression of the lack of both stability and pressure distribution area.
Using WC
The wheelchair user might have the habit of using reclining function of the wheelchair to empty a
catheter or a habit of pulling himself backwards and forwards on the wheelchair seat after having
visited the toilet or done catheterization. Then it is essential to make sure that the wheelchair user
is actually able to finish the process by lifting himself 100% from the seat. If he is not able to do so it
is a very risky behavior and you need to create alternatives to minimize the risk of creating shear
because if not the wheelchair user is continuously seated upon displaced and deformating tissue
probably resulting in a potential tissue damage.
Dressing and un-dressing
If it is a habit to use the wheelchair reclining function when dressing – perhaps to get more space
for an easier way to pull on clothes or a sling it is a very risky behavior. You need to find better
solutions to prevent this habit from creating displacement on the seat (friction) and in the tissue
underneath the skin – inside the body (shear).
Personal hygiene (and other kinds of body care)
It is a very risky behavior if the user perform his transfers TO a bath and toilet chair by a “low
transfer” if the user is in fact not able to finish the transfer by lifting himself 100% from the seat.
It is a very risky behavior too if it is a habit that the wheelchair user is continuously seated for more
than 15 minutes in a sling.
You ought to intervene and avoid this by eliminating the tissue deformation – meaning creating
stability and pressure distribution to the whole body.
Communication
If the anterior tilt in space need to be used beyond horizontal in order to reach a good working
position by the computer table and to reach the keyboard or perhaps to be able to see the text on
the screen it is a risky behavior you need to intervene in. To prevent this you must activate your
creative potential in order to optimize a stable and non-sliding displacement of the tissue and the
skeleton during work time for more than 15 minutes.
Transportation
If it is a habit to use the anterior tilt in space beyond horizontal to be seated or to enter the car –
either as a driver or as a passenger - it is a very risky behavior.
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If the recline function of the wheelchair is used either forward or backwards to enable the
wheelchair user to enter the car or even be able to drive it, or if the wheelchair user is performing a
“low transfer” from wheelchair to car seat without being able finally lifting himself 100% from the
seat it is a very risky behavior. A concrete analysis of the shear risk during driving is necessary.
Be aware of the total amount of driving time + the subsequent participation in activities,
treatments and medical examinations that all together might lead to a very long and risky challenge
to the body which is perhaps not sufficiently stable and optimally pressure distributed during
driving. Driving-related adjustments of the wheelchair or the car seat considered necessary during
driving might contradict the necessary continuous stability. It might be difficult to correct an
unsuitable seated position during driving and might allow shear a free rein for many hours – very
often an underestimated problem. Consider any possibilities to avoid these consequences even by
making suitable changes of the car.
Cooking
If the anterior tilt in space is used beyond horizontal perhaps to gain a good working height at the
kitchen table, sink or stove during cooking or if the footrests are removed it is a risky behavior, that
you need to reflect therapeutically upon. There is a need for less risky
working postures to prevent shear and friction in tissue and skin.
Be aware of heavy kitchen equipment and boxes with e.g. potatoes, flour,
beers and stuff like that. It should not be located on the lowest shelves or in
places with the most difficult accessibility, as it will cause a need for reaching
out beyond the wheelchair side - meaning a risky behavior – losing stability
and contact with the important 3 body points of contact to the chair: SIPS
and the two Tuber Ischii. The wheelchair user will slide to one side, perform
friction and shear - meaning deformation of tissue -, and will perhaps not
regain his upright position as he might not realize the sliding process.
Be aware of the fact that whet hands or hands with flower or bits of food
(during the process of cooking) might prevent the wheelchair user from
correcting his seated position after sliding till he is able to dry his hands – in
order not to soil his wheelchair. That is how even a well-adjusted wheelchair offering stability and
pressure distribution might result in a tissue damage during more than 15 minutes of a bad
position.
Go shopping
If it is a user habit for instance to reach out over his area of support for goods on the lowest or
highest shelves it might result in missing stable contact with his 3 important points of contact: SIPS
and the two Tuber Ischii between body and chair. The pelvis might tilt – seen from the frontal
plane.
If so, it will often not be possible to correct this properly until the user is at home again, and the
wheelchair user will not even be aware of the problem. If so, the time during which the shear is at
work will make a very serious risk.
Cleaning
If the wheelchair user has a habit of reaching out over his area of support to be able to do cleaning,
gardening, or perhaps other kinds of hard physical work it might be a serious risk factor. It may
cause loss of stability and contact with the important three body points to the chair: SIPS and the
two Tuber Ischii. If so, it can be necessary as OT to assist the wheelchair user in finding alternative
ways and tools to enable him to continue his activities.
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Washing/dishwashing
If the washing machine and/or the dishwasher is filled and emptied, for instance by reaching out
beyond the wheelchair side it means a risky behavior that needs your analysis to find alternative
solutions.
Resting
Is the wheelchair user resting by using the back recline and the footrest elevation it is a very risky
behavior. Partly because it usually is not possible to gain sufficient support and rest to the body –
which also means sufficient return of blood to the heart – in this position, partly because the
different possibilities of wheelchair adjustment involves a shear and friction generation. For that
reason avoid this practice.
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