1. The crash forces must be dissipated.

• The crash forces need to be distributed over the appropriate areas of the body, such as the bony structures, and not over soft structures, such as the abdomen.

• The stretch of the harness and bending of the seat as the crash forces proceed need to be accommodated. This sequence of time and stretch is important and necessary.

2. Crash protection systems prevent the impact of the occupant with the interior of the vehicle.

3. Crash protection systems prevent the ejection of the occupant from the vehicle.

For any crash protection system to work properly, it needs to keep the occupant safe.These principles should be used to develop safe guidelines for wheelchair transportation.

ANSI-RESNA and the Canadian Standards Association have finally developed guidelines and standards for transportable mobility devices and tie-down systems. A number of wheelchair manufacturers have tested their mobility bases with seating inserts and crash test dummies. The product tests conducted by these manufacturers used both wheelchair tie-downs and an occupant restraint system to secure the wheelchair and crash test dummy.

WHEELCHAIRS

Encourage the use of a child restraint system (car seat, safety vest, etc.) for as long as possible before transporting a child in a wheelchair.  Forty to sixty pounds is the maximum weight limit for most commercial forward-facing child restraint systems, and at this weight limit, children then switch to a booster seat.& &bsp; However, when more postural control and support are needed, there are excellent restraint systems on the market for adults and for children who weigh more than 40 to 60 pounds. After the decision to be transported in a wheelchair is made, the following areas need to be considered.

Seat Belts
The wheelchair should be equipped with an automobile-type of seat belt that fits snugly over the bony structure of the pelvis, not, over the abdomen. for a seat belt but can be used with the seat belt for added truck support and positioning. The seat belt must be firmly attached to the wheelchair frame and not to the insert or to removable parts of the wheelchair frame (e.g., armrests).

Modifying Whheelchair Frames - "Mr." or "Ms. Fix-it"
Wheelchairs are mechanical devices and from time to time may need minor repairs or adjustment.  A bolt or screw may need to be tightened, or a tire may need to be repaired.  These are often considered minor necessary repairs or adjustments.  However, major repairs to a wheelchair should not be attempted.  Never attempt to repair or modify a wheelchair frame or axle (e.g., drill holes, cut bars, weld additional pieces) without consulting the manufacturer.  In most cases these modifications will void the manufacturer's warranty as well as create potential weak points in the axle or frame.

Seating Insert Attachments
We often take wheelchair inserts for granted as an almost invisible but necessary part of the wheelchair.  It is important, however, to be sure that the seating insert is well secured to the frame of the wheelchair at the back and base.  Hook-and-loop fasteners, webbing, or buckle systems are not recommended to anchor the system to the wheelchair frame because they are less likely to hold the seating system in place during a crash.  When the system does not have to be removed from the mobility base, the seating unit should be permanently attached to its frame.

Headrests
The wheelchair user's head and neck should always be protected from whiplash.  A headrest is recommended for all wheelchairs and mobility devices as well as for standard upholstered wheelchair backs.  In most situations, for those who do not need a headrest-positioning device, the headrest could be used during transportation only. The headrest must be positioned accurately to provide protection. Vehicle headrest adjustments require it to be less than 1 inch from the back of the head, and for the middle of the headrest to be in line with the middle of the ears.  Check with a physical therapist or occupational therapist for proper adjustment.

Bands and Restraints
The head should not be restrained during transportation because this leaves the neck unprotected. Alternate solutions for persons requiring upper thoracic, neck, and head positioning (e.g., a halo-style device) could include a well-fitting chest harness, foam lap tray, or soft neck collar.

Lap Trays
Do not transport a child with the lap tray on the wheelchair. Lap trays were not designed to spread crash forces. In the event of a crash, a lap tray could cause severe abdominal injuries or become a flying missile and injure someone else.  Alternatives for positioning include using a foam tray or soft neck collar.

Tilt-in-Space or Recline
Unless ordered by a physician to do otherwise, do not transport a wheelchair user in a tilted or reclined position; be sure that the wheelchair is in the upright position. In a crash situation, a tilted wheelchair changes the body's center of gravity, which increases the torso load of the seat belts and potentially can alter their position, resulting in neck or spinal injury.  Because the casters and front edge of the wheelchair seat are the weakest points and sustain high forces in a forward crash, the collapse and downward compression of the front end of the wheelchair opens the seat-to-back angle of the frame.

Special Medical Conditions
Ensure that wheelchair users who have shunts, G-tubes, tracheotomies, or sensitive bone or skin conditions are not under pressure or friction in these areas from the seating and positioning straps or from the shoulder or lap portion of the vehicle tie-down system.  If necessary, have a discussion with the bus driver to learn the route.  A rough road or street condition may be a potential cause of injury for a fragile child.

Batteries
Gel electrolyte batteries are recommended for power mobility units because they are sealed.  Acid lead batteries could leak or spill if tipped.  Batteries are very heavy and only minimally secured to the wheelchair frame, usually in a plastic shroud secured with a webbing strap.

Anti-Tippers
The anti-tippers at the back of the wheelchair are designed to increase stability and prevent the wheelchair from tipping over (with normal use).  Be very careful when loading or unloading a wheelchair with anti-tippers, since if the wheelchair is not positioned properly on the bus’s wheelchair lift, they have a tendency to hang over the edge of the bus body, which may cause the chair to tip forward and possibly fall off the wheelchair lift.  They should be in the down position during transport.  Although it is unlikely that they would hold in a crash situation, they do add stability during normal driving starts, stops, and turns.

Rigid Positioning Devices
Rigid positioning devices can be useful components for postural control However, unless required by a physician, they should not be used during transport because they do not dissipate crash forces.

• Rigid pelvic bar: This structure is used instead of a belt system to control the position of the pelvis. Consideration should be given to using a belt system during transport.

• Rigid shoulder pods: These devices are used to maintain an upright trunk position. Consideration should be given to having them off during transport and using a soft neck collar, foam tray, or chest harness instead.  If they are flipped out of the way, they could pose a danger to the head and neck because the metal rods are exposed and close to the head, shoulders, and neck.

VEHICLE TIE-DOWN SYSTEMS

Never transport a person in a wheelchair without a restraint system. A tie-down system with an occupant restraint as well as wheelchair anchorage provides the best protection.  Most companies now produce shoulder and lap belt systems for the occupant in addition to the four-point wheelchair restraint system.  With this system, the wall and floor of the vehicle absorb the crash forces instead of the occupant of the wheelchair.  If a wheelchair tie-down were used without an occupant restraint system, the person would have to rely solely on the belts and restraints attached to the wheelchair.  This could cause serious injury to the wheelchair user if ejected from the chair, or simply from extreme contact with the belts and restraints attached to the wheelchair.  Seating and positioning aids do not qualify as automobile restraints.  However, in practice, there are still many commercial and private vehicles that have wheelchair tie-downs only without an occupant restraint component.

Homemade Tie-Downs
Homemade solutions may appear sturdy, but most would probably fail under crash conditions. Never recommend, construct, or use homemade anchor systems.

Loose Objects
down. Do not use bungee cords or other elasticized materials because they could snap in a crash. Protruding and loose objects can be tossed about in a crash and become deadly missiles for all occupants.

Transport Position
(Sitting so that the wheelchair is) rear facing is the safest direction for transport because most crashes are frontal, and the impact sends the body into the support of the surface behind the occupant.  This is the rationale behind rear-facing infant restraint systems.  However, front-facing transportation is recommended for the comfort of the traveler and because if the appropriate restraint system is in place, it is almost as safe as rear facing.

CONCLUSION

There are many issues for those responsible for safe transportation to consider when recommending equipment and accessories to be used while transporting persons who use wheelchairs.  Best practice indicates educating all persons involved, so they can make informed decisions. Wheelchairs and positioning accessories often come with labels to assist the user or service provider in proper use or positioning.  When working with clients on driving and transportation goals, occupational therapists should consider the following:

Part 1 - SAFE TRANSPORTATION FOR WHEELCHAIR USERS