Wheeled Mobility Devices Used as Seats in Motor Vehicles – what do we need to know?

Last week we looked at ISO standards – the history behind these and how they apply to wheelchairs.  This week we are looking at one particular standard – ISO 7176-19:2008 - Wheeled mobility devices used as seats in motor vehicles.  This standard is similar to the ANSI/RESNA WC19 standard, the recommended standard in North America, often referred to as WC19.  The standards surrounding wheelchairs and their safety for use as seats in vehicles is something therapists need to be aware of when prescribing wheelchairs for those who need to remain seated in their wheelchairs when traveling in a vehicle.  The ISO 7176-19 is deemed the minimum standard for wheelchairs that are used as seats in vehicles, while the ANSI/RENSA WC-19 has additional components to optimise wheelchair users safety. 

When we purchase a vehicle, we are presented with information as to how safe that car is likely to be in the event of an accident, for example a particular car may have an ANCAP (Australasian New Car Assessment Program) star rating telling us how well the car performed under crash testing, with a five star rating being a safer vehicle.  Manufacturers reduce the risk of death and injury in motor vehicle crashes using a systems approach to occupant protection, in which the vehicle, the vehicle seat and occupant restraint system (ie seat belt) each to contribute to a safety system. 

For wheelchair users who remain seated in the wheelchairs while travelling in their vehicles, a similar systems approach is also used, incorporating the wheelchair restraint system in the vehicle, the wheelchair and seating itself, and again the occupant restraint system. 

The wheelchair restraint system and the occupant restraint system are installed into vehicles by a person certified to complete the modifications to the relevant standard, with the modifications completed being appropriate to the wheelchair used – for example use of a hoist and tie down system that is rated for the type of chair used, with a power wheelchair requiring different specifications to a manual chair. 

The safety of wheelchair users while travelling in a vehicle is dependent on the wheelchair restraint and seat belts being used appropriately, for failure to do so can result in injury in situations where occupants seated in the standard vehicle seat may not be harmed at all.  Potentially a wheelchair that is not restrained properly in a vehicle can tip over if the vehicle turns sharply, or a seat belt that is not applied correctly can mean the occupant can come out of their seat and injure themselves on the interior of the vehicle if the vehicle stops suddenly.

Photo 2 source https://education.nsw.gov.au/public-schools/astp/contractors/safety-requirements

The use of these restraints is complemented by use of a wheelchair that meets the ISO7176-19 or WC19 standard to reduce the risk of injury to the end user.  The test for this standard is to subject the chair a forward facing crash test at 50km/hr with a 70kg crash test dummy.  This test is typically tested with the seating system associated with this chair, however after market seating products can be tested by the WC20 standard to establish their safety under crash conditions.  Chairs that meet the WC19 often use tie down points on the chair, these being four permanently labelled, easily accessible securement point brackets, however docking systems such as Ezi-lock and Dahl are also an option for some users.  Other aspects of the ISO 7176-19 and WC19 standards include use of seating systems that allow the seat belt to be positioned effectively and that there are that there are no sharp edges on the chair that may cause damage to either tie down points or the vehicle occupant restraint system. 

A person remaining in their wheelchair seat is often seen as a convenient means of travel, however use of the vehicle’s standard seat is considered the safest option for a person to travel.  Prior to considering vehicle modifications, questions to consider are 

• How well can the person transfer in/out of their wheelchair?  Can they safely transfer into the manufacturer installed car seat? This may involve use of a mobility vehicle to allow the person (and their chair) to be transferred up into the vehicle, where they can then transfer into the standard car seat and their chair be restrained for unoccupied travel. 
• For young children, or those who require assistance to transfer, the risk of injury to the carer when transferring the child/person in/out of the car seat needs to be weighed up against the risk of travelling in the wheelchair – where for many people, the risk of injury during the transfer outweighs the potential risk from travelling in their wheelchairs. 

If travelling in a wheelchair has been established to be the safer solution for the end user, considerations for the wheelchair include 

• What standard has the chair been certified to?  Has the chair been certified for occupied travel?  Some chairs are only certified for un-occupied travel, meaning it is not intended that the end user remain in the chair while travelling in a vehicle.  Information as to what standard the chair has been tested to is included in each chair’s user manual, or can be obtained from the dealer or supplier. 
• If a docking system is to be used, has the docking system been tested for the model of chair you are considering?
• Chairs that are custom built, eg custom manual wheelchairs, may not be certified for crash testing, but may have the features that the standards recommend.  The benefits and challenges of these chairs need to be discussed with the end users to ensure that they are making an informed choice about the crash testing status of these chairs.
• The pelvic positioning belts and/or harnesses used as positioning aids on the seating system are not intended for use as a vehicle restraint, although may be used in addition to the vehicle restraint system to ensure the user maintains an optimal position while travelling in their vehicle.
• While travelling in the vehicle, ideally the end user requires access to a head support to prevent injury to their neck in the event of an accident.  For some users, this may be installed as part of the vehicle modifications (eg for those driving their vehicles) however others may require a head support attached to their chair as part of their seating system.  When the head support is attached to the wheelchair, consideration needs to be given to how it is mounted – for example if mounted to the back support, the back support needs to be of sufficient height for the mounting to be effective.  

When the wheelchair is in the vehicle 

• The wheelchair needs to be restrained using the appropriate restraint system – for example use of tie downs attached to the identified tie down points on the chair.
• The person travelling in the wheelchair then also needs to be restrained using a certified three-point belt, to ensure they remain in their chair in the event of an accident.  Some wheelchair manufacturers offer the ability to fit a vehicle certified hip belt that a shoulder belt may attach to in a vehicle for ease of fitting. 

A person being able to use their wheelchair as a seat in a vehicle can be the difference between being able to access the community or needing to stay home, and use of standards can help keep wheelchair users as safe as possible while travelling in their chairs.

For further information please see

ANSI/RESNA WC19 - http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs

RESNA Position Statement on Wheelchairs used as Seats in Motor Vehicles - https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNAPositiononWheelchairsUsedasSeatsinMotorVehicles.pdf

Vehicle modifications

Mobility Engineering Australia - https://www.mobilityengineering.com.au/

Low Volume Vehicle Technical Association - https://www.lvvta.org.nz/documents.html#standards

Safety Ratings of Motor Vehicles - https://rightcar.govt.nz/safety-ratings 

Rachel Maher

Clinical Education Specialist 

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and later gained her Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.  

Rachel later moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.  

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

ISO Standards – What are they and why are they important?

ISO standards are a term many of us have heard of, and will be influenced by in our daily lives, but potentially do not know much about.

ISO is an independent, non-governmental international organisation, with membership of 164 national standards bodies.  The name ISO is derived from the Greek ‘isos’ meaning equal, with the name ISO being used in all countries around the world, regardless of what language is spoken.

ISO standards started with the essential question: what is the best way of doing this?  The first meeting to discuss international standards was in London in 1946, where 65 delegates from 25 countries met to discuss the future of International Standardisation, with ISO officially coming into existence in 1947 with 67 technical committees.   Today ISO is based in Geneva, Switzerland, with membership of 164 national standards bodies, 792 technical committees and sub-committees and over 23000 standards. 

Each technical committee is made up of independent experts nominated by ISO members, with the goal of each technical committee being to look at products and services with an eye towards ensuring safety, quality, reliability and effectiveness. 

Today the standards cover almost all aspects of technology and manufacturing, with each standard being drafted by a technical committee (TC) or sub-committee (SC) and taking approximately three years to confirm.  Each international standard is reviewed at least once every five years by all ISO member bodies, with the relevant TC/SC deciding whether the standard should be confirmed, revised or withdrawn.  Testing for each standard is reviewed by the technical committee to ensure they are appropriate and reasonable for a test lab or manufacturer to be able to apply, but also that they are meaningful for the end user.  Each standard is not intended to endorse specific solutions, just allow for a direct comparison of specific properties

ISO standards are present behind many aspects of our home and work lives, from the food we eat, the shoes we wear, the toys our children play with, the paper we use in our printers or the credit card we can use around the world.   One of the most popular standards is ISO 9001, this standard sets out the requirements for a quality management system, helping businesses and organisations be more efficient and improve customer satisfaction. 

ISO standards can also facilitate manufacturers working together to produce solutions that make our daily life safer and more convenient, for example, the use of ISOFIX to secure child car seats in vehicles.  Use of child car seats in vehicles is a solution that increases a child’s safety while travelling, however installing these car seats can be a challenge.  ISO 13216-1 relates to the the universal system for anchoring child restraint systems to vehicles, with the purpose of improving the safety of child restraints by making the installation of these seats easier and more reliable.  This standard has resulted in many car manufacturers installing ISOFIX anchor points in their cars (a metal loop hidden in the gap between the flat and upright parts of the seat) and child car seat manufacturers producing a product that installs into these anchor points.  For parents, using ISOFIX provides reassurance that they can install their child car seat correctly to maximise the safety benefits of the seat.  (This was a system that I used with both of my children and had no idea where the name derived from!) 

How does ISO standards relate to power wheelchairs?   The technical committee responsible for wheelchair standards is ISO/TC 173, Assistive products for persons with disability.   ISO/TC 173 was created in 1978, with the scope of standardisation in the field of assistive products and related services, to assist a person in compensating for reduced abilities.  This committee has developed numerous standards for persons with disability ranging from aids for ostomy (surgical opening for discharge of waste) and incontinence to assistive equipment helping people with a visual impairment use pedestrian crossings, to hoists for transferring.

From ISO/TC 173, Subcommittee SC 1 relates to wheelchairs.  This group is responsible development and maintenance of the ISO 7176 series, a 32 part series covering items such as static and dynamic stability, effectiveness of brakes, impact and fatigue strengths, obstacle climbing ability and wheeled mobility devices for use as seats in motor vehicles.

Each part of the standard is accompanied by a document that specifies the test methods and requirements for determining specified standard, for example ISO 7176-30: 2018, also known as Wheelchairs – Part 30: Wheelchairs for changing occupant posture – Test methods and requirements.  These guidelines specify the test methods and requirements for determining the safety and performance of a wheelchair that incorporates technology to alter the posture of the wheelchair user, for example a power wheelchair that offers power standing.

How do you find out what chairs have been tested to what standard?  The user manual of the chair will state what standards and regulations the chair meets the requirements of, including whether it has been tested to the ISO 7176 series.  Alternatively, the supplier or dealer who provide the chair should be able to tell you. 

This testing is often a big point of difference between high and lower cost power mobility options.  Mobility solutions that are lower cost are potentially manufactured from inferior materials or with an inferior design, where typically their user manuals will make little (or no) reference to any ISO testing.  This isn’t to say these mobility solutions are a poor choice, for a low cost mobility device may work well as a useful adjunct to a person’s mobility, for example a basic mobility scooter to allow a person to mobilise around a shopping mall independently.  However, this same device may not be safe or durable for a user who is dependant on a mobility device for their all-day mobility across multiple environments.  These users require a mobility solution that has been tested to ensure it is a safe and reliable device for everyday use, with ISO standards providing an independent means of establishing this. 

Next week we will take a closer look at ISO 7176-19:2008 - Wheelchairs Part 19: Wheeled mobility devices for use as seats in motor vehicles.  We will look at what parameters this standard tests and what other factors need to be considered when a person is using their wheelchair as a seat in a vehicle.

References

https://www.iso.org/home.html

For more information on ISOFIX https://youtu.be/W0sTvpyKgKY

Rachel Maher 

Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and later gained her Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.   

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.    

Rachel later moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.   

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

STEPtember: Cerebral Palsy Awareness and Research

September is a busy month of awareness days and activities, this week we are taking a look at STEPtember, a health and well being fundraising event in support of cerebral palsy.  STEPtember is an annual event held throughout the world to raise funds for cerebral palsy (CP) research and services, with the goal for participants to walk, swim, ride, wheel or spin their way to 10,000 steps per day for 28 days. 

Currently there are 34,000 people living with CP in Australia and approximately 10,000 people in New Zealand.   STEPtember is usually held in both Australia and New Zealand, however this year only Australia are participating due to COVID-19 related issues in New Zealand.

The funds raised from STEPtember support a wide range of services provided by the Cerebral Palsy Alliance (Australia), the ultimate going being to help people living with CP to live their best lives.  Initiatives highlighted for this year’s STEPtember campaign include identifying babies at risk and providing early intervention, supporting children with disabilities, and their families, in regional and remote areas, supporting access to sport programmes, and providing equipment and technology solutions.  One interesting project that may benefit more than those living in Australia is support of stem cell research, with researchers investigating stem cells as a possible treatment for CP.

Stem cell treatment is a complex topic.  Stem cells are grouped depending on the number of tissues they can be differentiated into (cited in Eggenburger et al 2019) with different stem cells obtained from different sources.  For stem cell research in the treatment of CP, the source of stem cells is typically umbilical cord blood or bone marrow.  These stem cells may be collected from the same person (ie stem cells used from an umbilical cord that had been stored, with the child receiving their own cells at a later date) or from a different person (ie a donor).  Use of umbilical cord blood or bone marrow has previously been limited to blood or immune disorders, however in more recent years, research is showing that it may also be of benefit in treating various neurological diseases (cited in Eggenburger et al 2019).

A systematic review and meta-analysis completed by Eggenberger et al, reviewed and combined the results of five studies, and suggested that stem cell treatment may result in an improvement in gross motor function with those diagnosed with CP, however the number of variables in the studies  makes establishing the size of the treatment benefit challenging.  One of the studies included was one by Sun et al, this study was more specific in the age of the children involved in the study (1 to 6 years) with all children receiving stem cells from their own, previously stored, umbilical cord blood.  The outcome of this study was interesting in that both groups of children (control and intervention groups) improved more than expected in their gross motor abilities (measured by the GMFM), highlighting that other treatment interventions were also working, and that those who received a larger dose of stem cells showed more improvement.  These studies highlight the need for further research into the topic, to establish what stem cells are more effective, and at what dose and at what age. 

Another project, identifying babies at risk, is important as research has shown that babies who have CP can be identified at a young age.  The systematic review completed by Novak, Morgan and Adde identified that a diagnosis can be accurately made before six months of corrected age, using magnetic resonance imaging and standardised assessments such as the Prechtl Qualitative Assessment of General Movements, and while the severity of the CP is more challenging to establish, early diagnosis allows the family and therapy team  to optimise infant motor and cognitive learning, as well as prevent secondary complications and enhance carer well-being. 

Overall, advances in diagnosis, prevention and treatment now mean that the incidence of CP is falling, and of those who are diagnosed, more children than ever will walk (Novak et al 2019).   In high income countries, two in three individuals diagnosed with CP will walk, three in four will talk and one in two will have normal intelligence (Novak 2017)

STEPtember also highlights the importance of movement in general, with the different ways people move highlighted in their choice of STEPtember trainers, from independently mobile, to mobile with a walking frame to mobile in a manual or power wheelchair.  Use of assistive technology can allow a person diagnosed with CP an efficient method of mobility, and potentially maximise their ability to participate in activities such as STEPtember, but also maximise their participation in family and school life. 

STEPtember offers a novel means of fundraising that is likely to benefit everyone who participates, and it is well timed so that participants can head into the warmer months happy and healthy following a bout of regular exercise.  While many of us may have missed the chance to officially join STEPtember, it isn’t too late for us to check out the STEPember website and jump on the bandwagon and getting moving!

For more information about STEPtember please see https://www.steptember.org.au/home 

References 

Eggenberger S., Boucard C., Schoeberlein A., et al  (2019) Stem cell treatment and cerebral palsy: Systemic review and metaanalysis World Journal of Stem Cells 11(10) 981-903

Sun J.M., Song A.W., Case L.E. et al (2017) Effect fo Autologous Cord Blood Infusion on Motor Function and Brain Connectivity in Young Children with Cerebral Palsy: A Randomised, Placebo-Controlled Trial Stem Cells Translational Medicine 6:2017-2078

Novak I., Morgan C., Adde L., (2017) Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy, Advances in Diagnosis and Treatment. JAMA Pediatr. 171(9): 897-901

Novak I., Morgan C., Fehey M., et al. (2019) State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.  Current Neurology and Neuroscience Reports 20:3

Rachel Maher 

Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and later gained her Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.   

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.    

Rachel later moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.   

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

 Duchenne Muscular Dystrophy Awareness Day – 7 September 2020

Monday 7^th September marks Duchenne Muscular Dystrophy (DMD) awareness day in both Australia and New Zealand, a global day to raise awareness of those affected by Duchenne and Becker Muscular Dystrophy (BMD).

DMD and BMD are both X-linked recessive disorders, caused by mutations in the dystrophin gene.  This mutation can be caused by a certain part of the DNA being doubled or changed, or be missing altogether, meaning the gene will not work as it is supposed to.  DMD and BMD can be passed down from a mother who is a carrier, or the gene can mutate spontaneously, and occurs in all ethnicities around the world.

The difference between Duchenne and Becker Muscular Dystrophy?  The dystrophin gene encodes the protein dystrophin, which is essential to healthy muscle growth and functioning.  Duchenne patients have a complete lack of the gene that produces dystrophin, while Becker patients have lower levels or a shorter version of the protein.  People diagnosed with Becker Muscular Dystrophy have less severe symptoms that often show later in life. 

Looking specifically at DMD, DMD affects between 1 in 3500 and 1 in 5000 live male births globally.  Affected boys become symptomatic at 3-5 years of age due to proximal muscle weakness, presenting with difficulties with running, more frequent falls and difficulty rising from the floor.  DMD is characterised by a well-known progression, including loss of mobility, reduced range of movement, development of deformities, and reduced independence with activity of daily living tasks. 

Introduction to Duchenne Muscular Dystrophy from World Duchenne Awareness Day on Vimeo.

At this stage there is no cure for DMD, however gene therapy offers potential for future treatment options.  The gene for DMD was one of the first genes discovered, however therapy options are proving challenging due to the range of causes of the mutations that result in DMD.  This range of causes means that one single gene therapy will not work for everyone diagnosed with DMD, however research is ongoing. 

A treatment option that is now well established is the use of corticosteroids.  Corticosteriod use is recommended by the current DMD care standards to start at around 4-6 years of age, and while the exact mechanism as to how they work is currently not well understood, evidence as to their benefit is being demonstrated.  Koeks et al reviewed data collected through the TREAT-NMD global DMD database, identifying that corticosteroid use is common in boys until the age of 14.  For those who had taken steroids, 79% were still ambulant at the age of 10, compared to 52% of those who had not.  The median age when a boy was unable to ambulate in non-steriod treated group was 10 years old, compared to 13 years in the steroid group.  Corticosteroids also significantly reduced the number requiring scoliosis surgery, the need for assisted ventilation and a lower incidence of cardio myopathy in those aged over 20 years of age. 

Another important aspect of therapy is promotion of daily stretching, particularly of the lower limbs, and use of positioning and equipment to prevent development of contractures and deformities.  The DMD Care standards reinforce that stretching needs to begin before loss of range of movement, and to initiate a standing programme using a standing device or wheelchair with upright positioning in the early non-ambulatory stage

This links to a current topic of conversation around the use of power standing wheelchairs for those diagnosed with DMD, with the chair being available for use as walking ability is lost. Research to support use of power standing chairs is currently limited, however evidence is emerging to support their use.  

Bayley et all explored the effect of power standing chairs on range of movement and pain in adolescents with DMD over a 20 week period, and suggested that joint range of movement was preserved during the study period, including a potential increase in hip flexor length, despite a progressive loss of ambulation.

In a qualitative study by Vorster, Evan and Murphy et al,  ‘Capacity to be able’ was the central theme that emerged from the data collected, with provision of a power stand up chair coming at a time when gross motor skills were declining.  A number of benefits were observed with the use of power standing chairs, including participating in school activities that were usually done in standing, such as art or science, to independence with personal care tasks such as toileting and brushing teeth.  More autonomy with participating in activities is considered important for adolescents and appeared to be associated with a strong emotional wellbeing.  An important finding of the study was that individuals who received the power stand up chair after becoming non ambulatory appeared to gain less benefit, highlighting the need for timely provision of power stand up chairs for this group.

Access to power standing chairs for those diagnosed with DMD can be variable depending on the experience of the wheelchair and seating therapist and the funding systems available.  While a power standing chair is not going to be suitable for all adolescents diagnosed with DMD, there is a group that have the potential to maintain a reasonable level of independence and well being if provided with one – at the right time.  The use of corticosteroids now means that boys are now entering adolescence when they lose the ability to walk, and are at an age typically associated with increasing independence.  Provision of a power standing chair will allow these adolescents to gain the therapeutic benefits associated with standing, in particular maintaining range of movement in their lower limbs, as well as maintaining independence in meaningful tasks at home and at school.  While these benefits are in no way a cure for the underlying muscle weakness associated with DMD, it may allow this generation of boys and adolescents with DMD to make the most of the adult life that advances of technology are gradually giving them.

Save Our Sons Duchenne Foundation https://www.saveoursons.org.au/ 

Muscular Dystrophy New Zealand https://www.mda.org.nz/ 

Standards of Care for Duchenne Muscular Dystrophy https://vision-dmd.info/revised-standards-of-care-for-duchenne-muscular-dystrophy/  

References 

Koeks Z., Bladen C.L., Salgado D., Clinical Outcomes in Duchenne Muscular Dystrophy: a Study of 5345 Patients from the TREAT-NMD DMD Global Database (2017) Journal of Neuromuscular Diseases 4 293-306 

Vorster N., Evans K., Murphy N., et al (2019) Power standing wheelchairs promote independence, health and community involvement in adolescents with Duchenne muscular dystrophy. Neuromuscular Disorders 29, 221-230 

Bayley K., Parkinson S., Jacoby P etc al (2020) Benefits of power standing wheelchair devices for adolescents with Duchenne muscular dystrophy in the first year of use. Journal of Paediatrics and Child Health 

Rachel Maher 

Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and later gained her Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.   

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.    

Rachel later moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.   

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.