The Importance of Comfort to Wheelchair Users – A Preliminary Study

Barbara Crane, Research Associate and Douglas Hobson, Ph. D.

University of Pittsburgh, Pittsburgh, PA

Abstract

This study describes preliminary research of seat comfort among individuals who use wheelchairs. Important issues investigated in this research include: determining the prevalence of discomfort as a problem, the importance of comfort, and possible factors that might mitigate this problem from the point of view of wheelchair users. Results indicate that that discomfort is a problem, that comfort is important to individuals who use wheelchairs, and that possible solutions from the wheelchair users perspective would include certain adjustable and dynamic wheelchair features. Future studies will expand these concepts to investigate the effectiveness of a dynamic seat interface at relieving discomfort.

Future research plans

The presented results are from phase one of a three-phase investigation of the effectiveness of dynamic seating in discomfort management. As a continuation of this research, a comfort assessment tool will be developed and tested for reliability, a prototype dynamic seating technology will be developed and will be introduced to a sample of the target population for in depth user trials. The final stage of this project will attempt to determine what new dynamic features should be made available in the marketplace to assist both users and seating clinicians in better management of wheelchair discomfort problems.

Background

Comfort is an important issue for individuals who use wheelchairs, particularly those with sensation. Discomfort or pain can lead to equipment abandonment, decreased satisfaction, and an inability to function throughout the day. Clinically, discomfort can be a difficult problem to address with the seating technology currently available. This is because the seating technology has been designed for postural support and for pressure management and not with the goal of optimal comfort in mind. In a 1999 study of consumer satisfaction with wheelchair devices, Weiss-Lambrou found that while comfort was the most important consumer criterion for satisfaction, it was what participants deemed the least satisfying thing about their wheelchair¹. In three separate studies of seating needs of elderly nursing home residents, discomfort was also reported as a significant and highly prevalent problem^2-4.

A panel of expert clinicians, researchers, manufacturers and consumers developed a list of several research priorities regarding seating comfort at the State of the Science conference held as a component of the RERC on Wheelchairs and Related Technology in February of 2001. Priorities identified include the need to determine the physiological and psychological basis of comfort and discomfort, the need to determine the magnitude of the problem of discomfort among those who use wheelchairs, and develop a tool that will help individuals quantify their levels of comfort and discomfort. These are all goals of this project.

The wheelchair seating research related to discomfort has been sparse. There are a handful of studies designed to look at consumer satisfaction that have identified discomfort as a problem^{1, 5-7}. There are also a few that have attempted to examine the concepts of comfort and discomfort as they relate to individuals who use wheelchairs^8-11. These studies have begun to examine discomfort within in a disability context, but have not identified a comprehensive, effective methodology for assessing comfort or resolving discomfort.

Research Questions

This research study examined the importance of comfort among a small group of severely involved individuals with intact sensation who use wheelchairs throughout the day. It was intended to answer the following questions: Is comfort important to individuals who use wheelchairs throughout the day? Is discomfort a problem area that is of concern to these individuals? Does this discomfort limit their ability to sit the number of hours they desire or limit their functional capacity throughout the day?

Methods

For this preliminary investigation, nine individuals were recruited from the greater Pittsburgh area. The inclusion criteria were: having a diagnosis of MS, MD, ALS, or post polio syndrome, being 18 years old or older, having used a wheelchair or scooter for at least three months, using a wheelchair or scooter as the means of primary locomotion (all day), and having some problems related to discomfort. Individuals were excluded if they had experienced a pressure ulcer within the last year.

The individuals were visited in their homes or other locations of their choosing. After a detailed explanation of the study and signing of an informed consent form, the participants were interviewed by the researcher using a structured questionnaire format. The questionnaire consisted of demographic information, information regarding the participants’ current wheelchair, and individual comments regarding the design of an “ideal” wheelchair seating system. The questions necessitated a combination of close-ended and open-ended responses from the individuals. A sample of these questions appears in Table 1. A descriptive analysis of the demographic information was completed. A weighted rank order was calculated on the responses regarding the importance of comfort and the importance of the adjustability features of a wheelchair.

All procedures were approved by the University of Pittsburgh’s Institutional Review Board prior to recruitment of any participants.

Question number	Question text	Format of answer
Part two, number 1	On an average day, how long do you spend in your seating system?	Close-ended – number of hours
Part two, number 2	What is a typical reason for getting out of your seating system?	Close- or open-ended – given 5 choices or able to list their own reason
Part three, number 4	Do you ignore your discomfort in order to function at your current level?	Close-ended – yes or no
Part three, number 8	How do you currently manage discomfort in your seating system?	Close- or open-ended – given 5 choices or able to list their own method
Part four, number 4	How important are these features of a seating system to you? Rated on a scale of 1 – 10, seven items: comfort, safety, mobility, ability to perform self care tasks, independent use of all features, ability to adjust multiple features, ability of caregiver to adjust features	Rated on a scale from 1 to 10

Table 1 – Sample of questions used

Results

All nine individuals recruited completed the questionnaire-based interview for this phase. Six were interviewed in their home and three were interviewed in a laboratory setting. Participants selected the setting in order to allow them to participate in the setting they felt most comfortable. The age of participants ranged from 18 to 66 years old with a mean age of 41 years old. Seven of the individuals were male and two were female. Primary diagnoses included: ALS – two participants, MS – two participants, MD – five participants. Additional descriptive data is summarized in Table 2. Five individuals interviewed used tilt in space seating systems (4 powered and one manual); three individuals used reclining seating systems (2 powered and one manual). Seven individuals used powered mobility systems and two individuals used manual systems.

Parameter	Number of individuals	Mean	Range
Age	9	41 years	18 to 66 years
Gender	7 male /2 female	na	na
Hours/day spent in chair	9	15 hours	8 to 24 hours
Height	9	67 inches	50 to 74 inches
Weight	9	159 pounds	94 to 220 pounds
Diagnosis	2 ALS; 2 MS; 5 MD	na	na

Table 2 – Results: Description of Sample

The range of hours the participants spent in their chairs on an average day was 8 to 24 with an average of 15 hours per day. Individuals reported three main reasons for getting out of their chairs – fatigue (3 individuals), functional need (5 individuals) and discomfort (1 individual). When asked if they experienced discomfort in their chairs, all nine reported that they did experience some level of discomfort. Five reported experiencing this discomfort on a daily basis, three reported experiencing discomfort at least once per week and one reported experiencing discomfort after only a few hours in the chair. All nine reported that they routinely ignored discomfort in order to participate in functional activities. The most common site of discomfort was the low back (seven individuals reporting this as an area of discomfort) and the second most common site was the buttocks (six individuals). Most individuals reported limited options for relief of discomfort. Three reported getting out of their chairs in order to relieve discomfort, four reported use of pain medications, six reported asking someone to reposition them in their chair, four reported repositioning themselves in their chair to the best of their abilities and one reported using the power tilt option in order to relieve discomfort. When asked about a history of skin breakdown problems, five individuals reported that they had experienced at least one episode of skin breakdown since they began using wheelchairs full time. Pertinent results are summarized in Table 3.

Question posed:	Response	n	Respose	n	Response	n
What is the reason for getting out of the chair?	Functional need	5	Fatigue	3	Discomfort	1
How often do you experience discomfort?	Every day	5	At least once per week	3	After a few hours	1
What methods do you use to relieve discomfort?	Get help to reposition	6	Pain medications or reposition self	4	Get out of the chair	3
Most common sites of discomfort	Low back	7	Buttocks	6	Legs	5
Do you experience discomfort?	Yes	9	No	0
Do you ignore discomfort in order to function?	Yes	9	No	0
Do you have a history of skin breakdown	Yes	5	No	4

Table 3 – Results: Summary of Interview Results

Two weighted rank orders were completed based on the data. The weighted rank order of various wheelchair attributes is as follows: comfort and mobility were tied as the most important attribute of a wheelchair, the ability to adjust multiple features was second, independent use of all features of the chair was third, the ability to perform self care tasks in the chair was fourth, and safety was fifth. For details on these rank orders, see Table 4. The next ranking was performed on the necessity or importance of having various features of the chair be adjustable. An adjustable control mechanism was ranked most important, adjustable leg rests was ranked second, adjustable seat temperature (if possible) was ranked third, adjustable arm rests was ranked fourth, adjustable head support was ranked fifth, adjustable lateral supports was ranked sixth, and an adjustable seat belt was ranked seventh and last of the features listed.

Parameter being ranked:	Weighted rank score	Rank order location
Seating system attributes:
Comfort	83	Tied - 1
Mobility	83	Tied - 1
Ability to adjust multiple features	81	2
Independent use of all features	71	3
Ability to performs self care in chair	67	4
Safety	66	5
Ability for care-giver to adjust multiple features	60	6
Importance of adjustability:
Control mechanism location	66*	1
Leg rests	62	2
Seat temperature	52	3
Arm rests	50	4
Head support	43*	5
Lateral supports	17*	6
Seat belt	16*	7

* not ranked by all individuals – (some felt this feature was not applicable to them)

Table 4 – Results: Weighted Rank Orders

Discussion

This preliminary study examined several elements related to seating discomfort in a sample of wheelchair users with intact sensation but severe motor incapacity, thus, unable to shift their weight. The purpose was to seek guidance as to the existence and nature of the problem for purposes of planning a more in-depth investigation, so the above results should be viewed from that perspective. In summary, all of the individuals indicated comfort is very important to them. This may have been influenced by the decision to specifically recruit individuals for this study who have had problems with discomfort, but we believe that these individuals are generally representative of the larger groups of individuals with similar diagnoses. The individuals in the study sample were unanimously agreed that discomfort is a significant problem for them, even if they felt that they were able to ignore discomfort in order to function (which most stated they did). As to the third question, the results are more difficult to interpret. When asked directly if discomfort limited their time in their chairs or limited function, all replied in the negative. However, when asked what they did in order to relieve discomfort, three reported that they got out of their chairs in order to manage discomfort. This would seem to be a conflicting result. Limitations of this preliminary study include: a small convenience sample of individuals, recruiting individuals who specifically have problems with discomfort, and difficulties with the subjects understanding the meaning of the specific questions which led to inconsistent explanations and interview content. These problems limit the generalizability of these results to a larger population. In spite of the limitations, this information adds to our general understanding of the problem of discomfort.

References

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7. Troy BS, Cooper R, Robertson RN, Grey TL. An analysis of work postures of manual wheelchiar users in the office environment. Journal of Rehabilitation Research and Development 1997;34:151-161.

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11. Nelham RL. Principles and practice in the manufacture of seating for the handicapped. Physiotherapy 1984;70:54-58.

Acknowledgements

This project was funded through the National Institute on Disability Rehabilitation and Research, grant #H133E990001 and conducted as a component of the Rehabilitation Engineering and Research Center on wheelchairs and related technology at the University of Pittsburgh.

Technical assistance in questionnaire construction was provided by Shirley Fitzgerald, Ph. D.