The SASCA

Assistive
Devices
Guidelines for
Persons with
Mobility
Impairment

March 2016
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Appendix to the Assistive Devices Guidelines
for Persons with Mobility Impairment

March 2016
Introduction: However the guidelines do not explain why these devices are
needed. This appendix addresses the “why” by illustrating the
Funding organisations spend hundreds of thousand of Rands
consequences of spinal cord injuries at each level of injury,
on the rehabilitation of persons with spinal cord injuries but
including case studies.
when these SCI patients are ready for discharge, there appears
to be a lack of understanding of what the out of hospital needs By illustrating why certain types of wheelchairs and other
are in order for the person with a SCI to basically just cope assistive devices are required, we trust that this appendix will
with life. provide funding organisations with an appreciation for the
wheelchair and assistive device requirements per level of
The Assistive Devices Guidelines for Persons with Mobility
spinal cord injury, as described in the Assistive Devices
Impairment provide guidelines on what types of wheelchairs
Guidelines for Persons with Mobility Impairment .
and other assistive devices are essential or the day to day
functioning of rehabilitated spinal cord injured persons. George Louw
H
publishes in the field of sexuality, sensitisation, access, medical
reimbursement and employment. We are thrilled to be able to
endorse and publish the SASCA Assistive Devices Guideline and
this appendix thereto.
We also value the partnership with SASCA and long may this
continue, as it has been extremely beneficial to the health
professional sector and also QASA members.
This assistive device guideline document has all the necessary
information in detail to understand the rightful assessment and
Foreword by the CEO of QASA: issuing of assistive devices for people with spinal cord injury and
QASA provides projects, products and services in order to will go a long way to ensure that quadriplegics and paraplegics
develop the capacity and give opportunity for quadriplegics and are receiving their assistive devices and mobility aids.
paraplegics in South Africa. QASA is also a strong lobby and We will continue to update this publication and distribute to
advocacy organisation ensuring human rights and dignity for our members, funders and health professionals equally.
members
QASA is proud to endorse this guideline knowing that members
Publishing information is important to keep our members of our organisation will be the ultimate beneficiary of the
informed and offer them guidelines and information valuable to knowledge gained in this publication.
their development , health & wellbeing and independence.
QASA, besides owning and publishing Rolling Inspiration Thank you to everybody involved in the collation of the
magazine, a bimonthly glossy magazine aimed at the information and support of this document.
constituency of “people with mobility impairments“, also Ari Seirlis.
p

Quadriplegia / TTe
etraplegia
Quadriplegia / Tetraplegia is the medical term used when a person has a spinal cord injury above the first thoracic vertebra.
Paralysis affects the cervical spinal nerves (C1-C8) resulting in paralysis in varying degrees in all four limbs. In addition to the arms
and legs being paralysed, the abdominal and chest muscles will also be affected resulting in weakened breathing and the inability to
properly cough and clear the chest.
Paraplegia
Paraplegia is a term used when the level of spinal cord injury occurs below the first thoracic spinal nerve (T1-S5). The degree at
which the person is paralysed can vary from the impairment of leg movement, to complete paralysis of the legs and abdomen up to
the nipple line. Paraplegics have full use of their arms and hands.

The ASIA Impairment Scale. Also known as the ASIA/ISCoS Exam and Grading System

A system used to describe spinal cord injury and help determine future rehabilitation and recovery needs. It is based on a patient ’s
ability to feel sensation at multiple points on the body and also tests motor function. Ideally, it ’s first given within 72 hours after the
initial injury.

Grade A: Complete lack of motor and sensory function below the level of injury (including the anal area)

Grade B: Some sensation below the level of the injury (including anal sensation)

Grade C: Some muscle movement is spared below the level of injury, but 50 percent of the muscles below the level of injury cannot
move against gravity.

Grade D: Most (more than 50 percent) of the muscles that are spared below the level of injury are strong enough to move against
gravity.

Grade E: All neurologic function has returned.

 Actions of the Spinal Nerves

Level Motor Function

C1–C6 Neck flexors
C1–T1 Neck extensors
C3, C4, C5 Supply diaphragm (mostly C4)
C5, C6 Move shoulder, raise arm (deltoid); flex elbow (biceps)
C6 Externally rotate (supinate) the arm
C6, C7 Extend elbow and wrist (triceps and wrist extensors); pronate wrist

C7, T1 Flex wrist; supply small muscles of the hand

T1–T6 Intercostals and trunk above the waist
T7–L1 Abdominal muscles
L1–L4 Flex thigh
L2, L3, L4 Adduct thigh; Extend leg at the knee (quadriceps femoris)
L4, L5, S1 Abduct thigh; Flex leg at the knee (hamstrings); Dorsiflex foot (tibialis
anterior); Extend toes

L5, S1, S2 Extend leg at the hip (gluteus maximus); Plantar flex foot and flex toes

Cervical Spinal Cord Injuries

C1-4 Fallout Impact

C1 – C4 injury
Most severe of the spinal cord injury levels.
Paralysis in arms, hands, trunk and legs.
Patient may not be able to breathe on his or her
own, cough, or control bowel or bladder
movements.
Ability to speak is sometimes impaired or reduced.
When all four limbs are affected, this is called
tetraplegia or quadriplegia.
Requires complete assistance with activities of daily
living, such as eating, dressing, bathing, and getting
in or out of bed.
May be able to use powered wheelchairs with
special controls to move around on their own.
Will not be able to drive a car on their own.
Requires 24-hour-a-day personal care.
 Cervical Spinal Cord Injuries

C5 Fallout Impact

C5 injury
Person can raise his or her arms and bend elbows.
Likely to have some or total paralysis of wrists,
hands, trunk and legs.
Can speak and use diaphragm, but breathing will
be weakened.
Will need assistance with most activities of daily
living, but once in a power wheelchair, can move
from one place to another independently.

Cervical Spinal Cord Injuries

C6 Fallout Impact

C6 injury
Nerves affect wrist extension.
Paralysis in hands, trunk and legs, typically
Should be able to bend wrists back.
Can speak and use diaphragm, but breathing will
be weakened.
Can move in and out of wheelchair and bed with
assistive equipment.
May also be able to drive an adapted vehicle.
Little or no voluntary control of bowel or bladder,
but may be able to manage on their own with
special equipment.
 Cervical Spinal Cord Injuries

C7 Fallout Impact

C7 injury
Nerves control elbow extension and some finger
extension.
Most can straighten their arm and have normal
movement of their shoulders.
Can do most activities of daily living by themselves,
but may need assistance with more difficult tasks.
May also be able to drive an adapted vehicle.
Little or no voluntary control of bowel or bladder,
but may be able to manage on their own with
special equipment.

Cervical Spinal Cord Injuries

C8 Fallout Impact

C8 injury
Nerves control some hand movement.
Should be able to grasp and release objects.
Can do most activities of daily living by themselves,
but may need assistance with more difficult tasks.
May also be able to drive an adapted vehicle.
Little or no voluntary control of bowel or bladder,
but may be able to manage on their own with
special equipment.
 Thoracic Spinal Cord Injuries

T1-T5 Fallout Impact

Thoracic Nerves (T1 – T5)

Corresponding nerves affect muscles, upper chest,
mid-back and abdominal muscles.
Arm and hand function is usually normal.
Injuries usually affect the trunk and legs (also
known as paraplegia).
Most likely use a manual wheelchair
Can learn to drive a modified car
Can stand in a standing frame, while others may
walk with braces

Thoracic Spinal Cord Injuries

T6-T12 Fallout Impact

Thoracic Nerves (T6 – T12)

Nerves affect muscles of the trunk (abdominal and
back muscles) depending on the level of injury.
Usually results in paraplegia
Normal upper-body movement
Fair to good ability to control and balance trunk
while in the seated position
Should be able to cough productively (if abdominal
muscles are intact)
Little or no voluntary control of bowel or bladder
but can manage on their own with special
equipment
Most likely use a manual wheelchair
Can learn to drive a modified car
Can stand in a standing frame, while others may
walk with braces.
 Lumbar and Sacral Spinal Cord Injuries

L1-S5 Fallout Impact

Lumbar Nerves (L1 – L5)

Injuries generally result in some loss of function in

the hips and legs.
Little or no voluntary control of bowel or bladder,
but can manage on their own with special
equipment
Depending on strength in the legs, may need a
wheelchair and may also walk with braces

Sacral Nerves (S1 – S5)

Injuries generally result in some loss of function in
the hips and legs.
Little or no voluntary control of bowel or bladder,
but can manage on their own with special
equipment
Most likely will be able to walk

CASE STUDIES IN QUADRIPLEGIA

Ari Seirlis Anthony Ghillino

Ari and Anthony both have quadriplegia from cervical spine injuries; Ari from a diving accident 30 years ago
and Anthony sustained his injury after the open bakkie in which he was sitting in the back, was involved in
an accident and rolled.
It is quite evident from the two photographs that Anthony ’s wheelchair requirements are more intensive
than Ari’s.
Ari’s level of lesion is C5 and the fallout is a spastic paralysis from his nipples downward. He therefore still
has shoulder function and partial/limited function of his arms and hands. This allows Ari to function well on
a manual wheelchair with power-assist – see the large hub of the wheel. It contains an electric motor that
he can switch on to assist him on inclines or diffficult terrain. In addition to the wheelchair Ari needs a
transfer board that helps his carer to move him from his chair into the driver seat of his car. He also requires
a commode to facilitate the use of a toilet. As CEO of QASA, Ari is very dependent on effficient use of his
computer. Voice activated software and devices that assist with typing and writing enhances his efficiency
and his quality of life.
Anthony’s lesion is just one vertebra up from Ari’s at C4 but this small anatomical difference has huge
functional implications. His fallout is from the shoulders down. This leaves him with a complete spastic
paralysis and no functionality of his arms, trunk and legs. Anthony’s needs are therefore far more
extensive than Ari’s. He needs a motorized wheelchair with electrical tilt in space and chin control.
In his words: “Electrical tilt in space enables me to change my position without being lifted and helps
prevent pressure sores. I also often feel dizzy, especially first thing in the morning and being able to tilt
alleviates the dizziness quickly. The chin control enables me to move my motorized wheelchair myself
giving me a level of independence.”
Further wheelchair needs include a head rest, a specialised pressure care cushion with waterproof
cover, a chest strap, padded foot rests and a padded knee pummel.
In Anthony’s words: “The head rest is for comfort, especially when travelling in a vehicle. The pressure
care cushion assists with pressure care/relief and helps to prevent pressure sores with the waterproof
cover necessary for unexpected mishaps. The chest strap prevents me from sliding over when I spasm
and secures me to the wheelchair when I am in a vehicle. The skin under my feet is extremely sensitive
and shoes give me pressure sores on the ball of my feet so the padded foot rests help to prevent
pressure sores from developing. The knee pummel prevents me from sliding forward and out of my
chair when I spasm. It "locks" me into position.”
Further to the above Anthony needs a number of other appliances, all with excellent reasons,
including:
For the bathroom; a commode with high backrest used in roll in shower.
For his bedroom; an electric wall mounted hoist, a high quality pressure care mattress and a CPAP
machine.
For traveling; a vehicle rear entry hoist/lift, a vehicle tie down system and portable ramps.
For his work; voice-activated software, an infrared head pointer remote mouse with puff switch and a
stylus with extension.

A CASE STUDY OF THORACIC PARAPLEGIA

Kanayo Okwuraiwe
Kanayo has a partial spastic paralysis from his bellybutton
downwards following a motor car accident fourteen years
ago.
The level of his injury is T10 which means that his stomach
muscles are compromised. This results in a loss of stability in
his trunk and therefore it places additional strain on his
shoulders, arms and wrists when he propels himself in his
wheelchair.

Kanayo currently uses a lightweight manual wheelchair. However due to his compromised stomach
muscles he would like to have a power-assist function for his wheelchair. In his words: “It will help
with wheeling, especially long distances and up hills and rough terrains, which is very difficult, more so
as a result of my recent diagnosis of Chronic Kidney Disease and my inability to exert a lot of energy
without tiring out.”
Kanayo is very prone to pressure sores. To assist with prevention he has a high risk pressure care
cushion for his wheelchair as well as a high quality pressure care mattress for his bed.
The partial loss of his stomach muscles left Kanayo with a compromised ability to balance his trunk. He
therefore has a taxi commode with an adapted backrest for full back support to assist him with his
bathroom activities.
Kanayo’s home has two steps to the front door which he is unable to scale without a ramp.
 A CASE STUDY OF LUMBAR PARAPLEGIA

Mzamo Twani
Mzamo was injured in a motor car accident five years ago. The level of her spinal cord injury was at
L1-L2, leaving her with a complete spastic paralysis from the waist down.
Mzamo requires a manual wheelchair with height adjustable and removable armrests.
Inherownwords:“Armrestshelpsalotduringpressurereliefandmakeiteasyformeto getinand
outofitindependently.” (Pressurerelief:Pressuresorepreventionincludesliftingthebuttocks
fromtheseateveryonceinawhiletorestorecirculation.)
In addition she needs the following appliances:
Bathroom: A taxi commode with adapted backrest for full back support for assistance with toilet
and showering.
General: A transfer board for quick and easy independent transfer from her wheelchair to e.g. a
car seat.

From the case studies it is quite evident that fallout from injuries that appear similar can be vastly
different. Millimeters differentiate between reasonable functionality and almost complete loss of
functionality.
Lower level injuries that at first glance appear to be “less severe” often require functional aids that are
not indicated for higher level injuries.
The need for assistive devices therefore cannot be simplistically split into “paraplegic needs” and
“quadriplegic needs”. Each person needs to be assessed individually.

Sources used in compiling this appendix:

1 Shepherd Center; Understanding Spinal Cord Injuries.
2 Apparelysed; Spinal Cord Injury Peer Support
3 Wikipaedia; Spinal Cord Injury