Prolonged wheelchair sitting and how to combat the effects

Recently there was an article in the Vancouver Province newspaper about a study revealing that how too much sitting is linked to shortened lives. Obviously for those who rely on wheelchairs for mobility, this is a concern. So on Twitter...

BFWriter from Vancouver, British Columbia asks:

If too much sitting is linked to shortened lifespans, then what can wheelchair users do about it?

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This is a very good question and it can vary from person to person. I have very good use of my upper body so most of my answers will be based on that. However, there are those who do not; I will try my best to address as much as I can.

When someone relies almost exclusively on a wheelchair for mobility, his/her body often undergo some changes, including (but not limited to):

• reduced bone density (or osteoporosis)
  
• reduced/atrophied muscles
  
• skin breakdown (such as pressure sores, a.k.a. "bed sores")
  
• spasticity/spasms
  
• changes in blood pressure and blood flow
  
• cardiovascular conditions
  
• contractures and joint problems
  

Some of these are for spinal cord injuries or paralysis, but I want to focus on wheelchair use in general (regardless of the type of condition someone has).

One of the most common tools used to combat the complications of prolonged sitting is the standing frame. There are several types, but basically they look like this.

An example of a standing frame.

To use one, the person simply transfers from a wheelchair to the stander and perhaps get strapped in (if there are straps). Once properly positioned, there will be a hydraulic pump that raises the person up. This video demonstrates:

However, not all standing frames can move around like that one. Most of them remain stationary. They are not meant to be a mobility device, but rather a device used to force someone's body to stand if he/she is unable to stand independently.

What this does is increase weight-bearing. By doing so, it maintains bone density (the bones are being used), it forces some muscles to do something new (which helps prevent atrophy), it allows the body to be in a new position (which can help with spasticity) and can also force the heart to pump quicker (due to more work needed to keep blood flowing in an upright standing position).

Other benefits can include reducing pressure on parts of the body usually involved in sitting (reducing the incidence of pressure sores), preventing scoliosis (by forcing someone to stand up straight and not slouch), aiding in bladder and bowel control (for those with spinal cord injury or paralysis, by using gravity and "stretching out" the areas involved) and psychological improvement (no more being short and always looking UP to things/people).

While this is all good, some people may have problems with standing frames. I remember when I had to stand for the first time since acquiring my disability, I nearly passed out because I was unprepared for the sudden change in blood pressure. Some people may still have this problem years later; light-headedness and slight dizziness can occur, which may prevent some people from using a standing frame too often.

There are also wheelchairs that can elevate someone to a more upright position. Some wheelchairs can help someone stand up partially, and others can stand completely.

Wheelchair with partial elevation.

Wheelchair with complete elevation.

While they have some of the same benefits as standing frames, the obvious drawback to these wheelchairs is practicality. They weigh a lot more than the aluminum and titanium wheelchairs that are often used, which can result in an increase of shoulder muscle injuries, and they can be difficult to transport for wheelchair users who drive cars, especially cars without wheelchair lifts or ramps.

These are the equipment-related options that can be used. However, can something be done without needing to use expensive equipment? Certainly.

One of the best ways to combat the complications of sitting is to go to the pool. This can be in the form of pool therapy or a casual swim. Being in the water puts more pressure on bones and muscles to fight water resistance; simply having to breathe harder in the water is proof enough of that.

I find that even with limited movement and sensation in my lower body, I can still take advantage of the water for weight bearing. At the shallow end, the water has a peculiar ability to support my weight yet allow me to "stand" with some weight on my legs; it is almost 50% standing on my own and 50% supporting my weight. The water also puts pressure on my muscles; since I have some movement, that can be used to try to increase strength. This can actually prove to be a bigger benefit than using standing frames!

Another thing I do is stretching on a yoga mat. Stretching muscles is important because those mobility problems are prone to contractures (shortening of muscle due to lack of use, resulting in reduced joint mobility). In addition, I have some joint pain in places where I have sensation and I suspect that for places where I lack sensation, it might be the same story. In general, I can independently stretch my lower body relatively well; if I want to "go the extra mile," I would require some assistance, but those with good use of their upper bodies should be able to stretch well.

There is another option that is not as widely used as standing frames, standing wheelchairs, swimming or stretching. That is functional electrical stimulation (FES). Basically, it involves electrodes that are attached to muscles that are paralyzed and small electric currents are used to activate and perhaps reprogram those muscles.

I am not an expert on FES, nor do I use it. From what I can find out, it is not right for everyone (which may be why it was never suggested to me). It does not repair spinal cord damage but rather it attempts to recover specific muscular functions. From what I can tell, it does not directly address the issues on the list that I put together at the beginning of this post.

Also, from what I can find, if someone is unable to stand, FES is unlikely to change that; however, if someone is already able to stand, FES can help with how the muscles move. In other words, it does not necessarily help someone achieve the ability to stand if the person does not already have that ability.

In the occasional cases where it does help someone achieve walking ability, one still needs 6-8 times more energy than able-bodied people to walk with FES. It is not practical walking (it cannot be sustained for a long period of time) and hence the person will still likely spend the vast majority of his/her time in a wheelchair.

(I may be wrong about this; I'm simply going by what I can find through some research. Unfortunately the studies out there are not very unified.)

This has been a long and somewhat complex post. I am sure there are other things that wheelchair users do to help with standing or increasing the time spent outside the wheelchair; these are just a few of the ways to do it.