The wheelchair

The problem

Most wheelchair falls do not happen rolling down the street. They happen in the second when the person stands up or sits down and the chair, with no brake on, rolls away just as they put their weight on it.

What is happening underneath

The chair is built to move. If it is not braked, any weight the person puts on one side pushes it, and it rolls away exactly when it should be still. That is why the brake is not a detail: it comes first.

Step by step

1. Get to know the parts: the two large rear wheels with their hand rims, the two small front wheels that swivel (casters), the two brakes (the levers over the large wheels), the footrests that lift up or come off, the armrests, the push handles at the back, and the anti-tip bars low at the back.
2. Before any movement of the person, lock both brakes. Both, not one.
3. Check that it is braked: push the chair gently. It must not roll.
4. To let the person put their feet on the floor, lift or remove the footrests first. Never let them step on the footrest.
5. When you leave the person alone, keep both brakes locked and the anti-tip bars in the safe position.

The problem

Spending many hours badly seated harms the body without showing it. Pressure sores (skin wounds from pressure), back pain, and faster tiredness appear. The good news is that recognizing good posture is simple.

What is happening underneath

The key to everything is the pelvis: if it is stable and well back, resting against the backrest, the weight spreads evenly across the buttocks and thighs, and the person stays as upright as their body allows. When the pelvis slides forward, leans to one side, or rolls back, the weight stops spreading and lands on a single point. That is where the skin gets hurt.

You may have heard the idea of "90-90-90" (hips, knees and ankles near 90 degrees). It works as a reference for a person with good trunk control and no special needs, but it is not a rule for everyone. Stiff hips, tight muscles behind the thigh, or changes in the spine can make that right-angle posture painful or impossible to hold, and can make the person slide. The goal is not to force angles: it is to find the most stable, comfortable upright posture for that person.

The three risk postures (to recognize them)

• Slid forward (PAC-02): the bottom moves to the edge, the back curves, the weight lands on the lower bone (the sacrum). Risk of a pressure sore.
• Leaning to one side (PAC-03): all the weight on one buttock and one side. Risk of a sore and of falling.
• Knees higher than hips (PAC-04): almost always from a badly set footrest or a sunken seat. It pushes the person back and loads the sacrum.

Step by step (correct posture, PAC-01)

1. Hips well back, touching the backrest. This is the most important thing of all.
2. Back supported and as straight as is comfortable. Slouching for a long time damages the skin.
3. Weight spread evenly between both buttocks, not tipped to one side.
4. Feet flat (heel and sole), not hanging or on tiptoe.
5. Check from time to time that the person has not slid or leaned, and correct it (see card A5).

The problem

The skin over the bones of the bottom and hips is the first to break down when someone spends many hours seated. A good cushion spreads the pressure, but on its own it is not enough: the weight has to be moved often.

What is happening underneath

Seated, almost all the person's weight lands on two small bones. Without cushioning and movement, that pressure cuts off the blood supply to the skin there and, within hours, the injury begins. The cushion spreads the weight over a larger surface, and the changes of position bring the circulation back.

Step by step

1. Use a cushion made for this (good-density foam, gel, or air), not an ordinary pillow. The right type is best chosen by a professional, based on the person's weight and risk.
2. Place it with the correct face up. Many have a label or a cover with a zipper at the back.
3. Seat the person well back, centered on the cushion.
4. Do pressure relief often: every 15 to 30 minutes, for 30 to 90 seconds. If the person can, have them lean forward or to each side to lift the bottom off the seat. If they cannot do it alone, help them do it routinely.
5. Check the skin every time the person moves to bed. Look for red areas that do not fade when the pressure is removed.

The problem

A badly set footrest changes the whole posture. If it sits too high, it raises the knees and pushes the weight onto the sacrum. If it sits too low or is not used, the feet hang and drag.

What is happening underneath

The feet are the base of the seated person. If the base is wrong, the hip shifts and the weight stops spreading. Footrest too high means knees up, which means a loaded sacrum. Feet hanging means poor circulation and swollen ankles.

Step by step

1. With the person seated well back, set the footrest so the thigh rests evenly and the whole foot is supported, without the knees rising higher than the hip.
2. The foot should be flat, heel and sole, not on tiptoe or in the air.
3. Leave a small gap between the footrest and the floor, about 2 inches (5 cm), so it does not catch.
4. To let the person stand up or sit down, lift or remove the footrest first, always.

The problem

Over the hours, the person slides forward in the seat. The reflex is to pull them up by the arms or the armpits, and that hurts their shoulder and the caregiver's back.

What is happening underneath

To get the hips back you do not "lift" the person, you slide them back. The force comes from the caregiver's legs, not the lower back. If the person can push with their own legs, that push does almost all the work.

Step by step

1. Lock both brakes.
2. Tell the person what you are going to do and ask them to help if they can. Never let them hang from your neck.
3. If they can help: have them cross their arms over the chest, plant their feet firmly and, on the count of three, push with their legs while you guide the hips back.
4. To hold them without hurting, use a transfer belt around the person's waist, not their clothing or arms.
5. With two people: one on each side, hold the belt or the hips, and on the count of three slide the person back.
6. The caregiver: feet apart, knees bent, back straight, the person close to your body. Turn by moving your feet, not by twisting your waist (see CUI-05).

The problem

On flat ground, pushing seems easy. But the level changes, the ramps, and the street curbs are where the person falls forward or the chair gets away.

What is happening underneath

The chair has small front wheels that catch on any step or hole. To get over a level change you have to relieve those front wheels, tilting the chair slightly back with the tipping bar (the small bar low at the back, that you press with your foot).

Step by step

On flat ground:

1. Firm hands on both handles, a calm pace.
2. Watch the floor ahead: holes, cables, loose rugs.

To go up a curb or low step (facing forward):

1. Bring the chair forward to the edge.
2. Press the tipping bar and lower the handles to lift the small front wheels.
3. Rest those small wheels on top of the step. Then, using your leg strength, bring the large wheels up by pushing and lifting gently on the handles. The person can help by pushing the rims forward.

To go down a curb or low step (backward):

1. Turn the chair: the large rear wheels are at the edge and you step down first, looking back.
2. Lower the large wheels slowly, controlling with the handles, keeping the chair tilted slightly back so the small wheels do not drop suddenly. Never facing forward and abruptly.

On a ramp:

1. To go up, push from behind with your body close to the chair, which always faces up the slope.
2. To go down a gentle ramp, go forward, slow and controlled, keeping the person's weight back. On a steep slope, or if the person tends to fall forward, go down backward and slowly, or find another route.

If a second helper is needed:

1. The second helper holds the frame of the chair, never the footrests.