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AT FOR P OINT A TO B
WHEELED MOBILITYAS A TOOL
TOWARD INDEPENDENCE Midnight Sun
Assistive Technology Conference
August 5, 2009
Presented by
Lisa E. Maurer MS, PT, ATP
with
Jerry Godden, CRTS, ATPWayne Gould, CRTS, ATP
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__________________________________________________________________
INTRODUCTIONS __________________________________________________________________
THE S PEAKERS
Lisa Maurer MS, PT, ATP is the Program Coordinator at The Wheelchair and Seating Clinic at Providence. A physical therapist for 19 years, and a Certified Assistive Technology Practitioner since 1997, she has extensive experience in multi-disciplinary Assistive Technology services,specializing in seating and mobility.
Jerry Godden, ATP is a Rehabilitation Technology Supplier with Geneva Woods Home Medical Supply in Anchorage. An advocate for people with disability s since 1990, and a Certified Assistive Technology Practitioner since 2004, he 13 years of experience in custom rehab equipment.
Wayne Gould, CRTS, ATP is a Rehabilitation Technology Supplier and Rehab Manager at Frontier Medical in Anchorage. He been working with people with disabilities for 20 years, and has 10 years of experience in custom rehab equipment.
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_________________________________________________________________
OBJECTIVES __________________________________________________________________
Participants will understand the role of mobility products as assistive technology.
Participants will demonstrate knowledge of the referral process for obtaining recommendations forwheeled mobility products.
Participants will have an understanding of the evaluation process, funding coverage criteria, anddocumentation requirements for mobility products.
Participants will have an understanding of the various types of wheelchairs currently available.
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_________________________________________________________________ HISTORY
__________________________________________________________________
WHEELCHAIRS AS ASSISTIVE TECHNOLOGY ?
Excerpts from CMS s Decision Memorandum for Mobility Assistive Equipment (CAG-00274N), May 5,2005:The use of assistive technology to aid ambulation goes back into prehistoric times when the simplest crutchesand canes to compensate for functional disabilities were fashioned from sticks. Since then, the evolution ofmobility assistance equipment has become increasingly more technological - from King Phillip II of Spain s rollingchair with foot rests in 1595 to the paraplegic watchmaker Stephen Farfler s self propelled chair which he built forhimself in 1655 at the age of 22 to the specialized power wheelchairs of today.
For many beneficiaries, a device of some sort is compensation for (a) mobility deficit.
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_________________________________________________________________
DEFINITIONS __________________________________________________________________
Wikipedia: Assistive technology (AT) is a generic term that includes assistive, adaptive, and rehabilitative devices for people with disabilities and includes the process used in selecting, locating, and using themAT promotes greater independence by enabling people to perform tasks that they were formerly unable to accomplish, or had great difficulty accomplishing, by providing enhancements to or changed methods of interacting with the technology needed to accomplish such tasks.
Durable Medical Equipment (DME): an assistive technology product
Seating products that assist people to sit comfortably and safely (seating systems, cushions,therapeutic seats)
Standing products to support people with disabilities in the standing position whilemaintaining/improving their health (standing frame, standing wheelchair, active stander).
Walking products to aid people with disabilities who are able to walk or stand with assistance (canes,
crutches, walkers, gait trainers). Advanced technology walking products to aid people with disabilities, such as paraplegia or cerebral
palsy, who would not at all able to walk or stand exoskeletons). Wheeled mobility products that enable people with reduced mobility to move freely indoors and
outdoors (wheelchairs/scooters) Robot-aided rehabilitation is a sensory-motor rehabilitation technique based on the use of robots and
mechatronic devices
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CENTERS FOR MEDICARE AND MEDICAID S ERVICES
CHANGING DEFINITIONS
Excerpts from CMS s Decision Memorandum for Mobility Assistive Equipment (CAG-00274N), May 5,2005:
Recent allegations of wheelchair fraud and abuse have focused considerable public interest on the provision of wheelchairs under the Medicare benefit. The agency has responded with a multifaceted plan to ensure the appropriate prescription of wheelchairs to beneficiaries who need them.
Mobility Assistive Equipment (MAE): described by CMS as:(equipment which is) reasonable and necessary for beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living such as toileting, feeding,dressing, grooming, and bathing in customary locations in the home.
Includes devices such as: canes crutches mobile geriatric chairs motorized wheelchairs
quad-canes rolling chairs safety rollers walkers manual wheelchairs power operated wheelchairs specially sized wheelchairs power operated vehicles
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_________________________________________________________________
SERVICE DELIVERY MODEL __________________________________________________________________
THE GOOD OLD DAYS
THE HERE AND NOW
The demand in health care today is to do everything we used to do with the same amount of money or less,
and with the same staff or less.
- Mark Schmeler, OTR/L, ATP 1999.
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_________________________________________________________________
INFORMATION GATHERING __________________________________________________________________
REFERRAL AND INTAKE
Wheelchair and Seating Clinic Referral Form (see Appendix)Key Information:
Client contact info
Client Date of Birth Diagnoses Funding sources Physician contact info
Reason for Referral: Why is evaluation being requested? What type of wheelchair or equipment being used?
In what condition is the current equipment? Current skin breakdown?
Physician Order
Payor Authorization (VA, TriWest)
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P RE -SCREENING
Clinical review
Enough information to schedule?Request for additional information/reports if needed
Therapist reports School Private
Medical reportsRehabilitation Technology Supplier information
Past equipment Documentation on past attempts at obtaining equipment
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Determination of servicesSeating/Mobility Evaluation
Clients typically have one or more of the following impairments: Impaired mobility function Impaired postural control or alignment Inappropriate wheelchair or seating system Discomfort with prolonged sitting Endurance limitations affecting mobility and/or functional abilities Current skin breakdown History of compromised skin integrity
Severe deformities Need for customized seating intervention Chronic or severe pain related to positioning/prolonged sitting Severe spasticity or postural instability which compromises safety and/or mobility
function Medical issues necessitate Physical Medicine examination prior to evaluation of
positioning and mobility needs.
General Therapy Evaluation/TreatmentPT Evaluation is a component of the Wheelchair and Seating Evaluation.General PT or OT evaluation may be useful to determine need for further services
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Determination of services (contd)Other Assistive Technology Services
Augmentative communicationEnvironmental controlComputer accessHome or worksite modificationJob accommodationVision or hearing aidsVehicle modificationDriving Evaluation
Comprehensive Assistive Technology Evaluation
Client has needs spanning all areas of assistive technology, or his/her needs are verycomplex, requiring the involvement of specialists in several disciplines.
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Determination of team membersFamily and caregivers are a givenRole of therapists
Physical Therapist Evaluates physical performance and mobility function, balance, coordination, and
posture Brings knowledge of anatomy, palpation of bony landmarks, lower
extremity/pelvic/trunk range of motion/flexibility Division of labor: wheelchairs and accessories
Occupational Therapist Evaluates functional, perceptual, and cognitive performance; sensorimotor
impairments; and posture Brings knowledge of anatomy, upper extremity/hand range of motion/flexibility, fine
motor function, access, and environmental accessibility Division of labor: cushions and backs
Assistive Technology Practitioner Clinician has RESNA required clinical experience and credentials, and has passed
the RESNA national certification examination.
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Determination of team members (contd)Role of supplier
Works with the evaluation team to recommend technology options, procures theequipment through funding source, delivers and fits equipment, trains client/family inuse, maintains and repairs equipment
Rehabilitation Technology Supplier NRRTS definition
A SPECIALIST WHO PROVIDES ENABLING TECHNOLOGY IN THE AREAS OF WHEELEDMOBILITY, SEATING AND ALTERNATIVE POSITIONING , AMBULATION ASSISTANCE , ENVIRONMENTAL CONTROL , AUGMENTED COMMUNICATION , AND/OR ACTIVITIES OFDAILY LIVING . EMPLOYED BY A COMPANY THAT SELLS DURABLE MEDICAL EQUIPMENT AND OFFERSCONSUMERS PRODUCT CHOICES , ALONG WITH PRICING AND FUNDING INFORMATION . MEETS BASIC STANDARDS OF ACCEPTABLE PRACTICE IN THE PROVISION OFEQUIPMENT , INCLUDING : ORDERING , ASSEMBLING , ADJUSTING , DELIVERING , ANDPROVIDING ON -GOING SUPPORT AND SERVICE
Credentialing CRTS: C ERTIFIED REHABILITATION TECHNOLOGY S UPPLIER
Has met NARTS certification requirements for rehabilitation technologysuppliers
ATP: A SSISTIVE TECHNOLOGY P RACTITIONER Has RESNA required clinical experience and credentials, and has passedthe RESNA national certification examination for assistive technologypractitioners.
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Determination of team members (contd)Durable Medical Equipment Dealer/Supplier/Vendor
Essentially performs the same functions as the RTS, but is not certified, and notbound to the standards of the CRTS Scope of practice and level of experience varies greatly Choose wisely based upon reputation, credentials, demonstrated knowledge, and
past experience.
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Rehabilitation Technology Supplier Selection Criteria Client is first priority
Responsive to clientsTimely
Available in emergency situations Willingness to be a team player
Responsive to therapists and other team membersTimelyAvailable as necessary
Relationships with a variety of manufacturers Wide range of technologies and services Availability of equipment for trials prior to procurement High value placed on informing and educating clients Knowledge of service provision
ProcurementCoverage criteriaRequired documentationPayor specific processes and proceduresHandling of denials and appeals
Repair and servicingWarranty servicing and repairWillingness to consider servicing equipment provided by other dealers
Qualified and competent staff Trained regarding specific technologiesAttendance of manufacturers technical schools
Regular continuing education/equipment inservicesAttendance of trade showsRTS Certification
Membership in NRRTS, NAMES, RESNA Adherence to NRRTS and NAMES Standards of Practice Joint Commission accreditation Receptive to new ideas and techniques
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Other team members
Physician (MD)
Determines diagnoses and prognosis, writes orders for the evaluation, certifies medicalnecessity of equipment by signing required documentation Physiatrist and Orthopaedic Surgeons are often more involved in the evaluation process,
and are often team members in some settings
SpeechLanguage Pathologist Evaluates cognitive and language abilities, and oral motor function (speech, swallowing,
drooling) Typically involved if seating/positioning affects swallowing, communication, or
augmentative communication use, or if cognitive factors have a significant affect on
mobility function Division of labor: mounting of AAC device, access of AAC device, integration of AAC
device with wheelchair where appropriate.
School Therapists, Teachers May provide valuable information relating to positioning and mobility function within the
educational setting; may identify accessibility and transportation concerns/requirements. Equipment may affect current treatment, treatment plan, and goals.
Private Therapists Client may be receiving general therapy services elsewhere, but therapists may not be
able to complete seating/mobility evaluation. Incorporate their input, and preventduplication of services or conflict of therapeutic goals. Many payors will not cover bothservices, but in some case will recognize the role of PT and OT in seating/mobility as aseparate specialized service.
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Other team members (cont d)
Rehabilitation Engineer
Modifies equipment to meet the client
s specific needs, designs and fabricates customizedequipment when commercially available products are inappropriate.
Nurse Caregiver Specialist in wound management (enterostomal nurse)
Orthotist/Prosthetist Typically involved when seating intervention consists of an actual orthosis or prothesis
(i.e. polypropylene TLSO, bilateral hip disarticulation or hemipelvectomy prosthesis)
Case ManagerPayorEmployerOther Support Systems
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VERIFICATION OF BENEFITS
PT/OT coverageIf currently receiving general therapy services by another provider, ensure coverage forPT/OT for seating/mobility as a specialized service (vs. duplication of services)
Coverage for extended evaluation/extended evaluation ratesMay request information on content of evaluation, length of time required
Requirement for use of specific RTS/DealerSome payors have participating RTS/Dealers that they will use exclusively
Some state agencies may require several bids before processing through one RTS/Dealer;some RTS/Dealers may not wish to be involved if they will not get the sale.
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VERIFICATION OF BENEFITS (CONT D)
Coverage of durable medical equipmentRTS/Dealer will handle funding issues, but therapists must have general knowledge toplan for the evaluation, select equipment, and complete documentation.Funding source should not determine the equipment evaluated or drive the selectionprocess, but must be taken into consideration.Payor for equipment may be different from payor for servicesCovered items
Allowables, caps
Percentages
Amount of client responsibility may limit options
Some clients may not wish to be evaluated if they are responsible for a large portionof the cost.Medical necessity vs. educational, vocational or other restriction on environment
Appropriate for use in home environment
Use outside of payorcovered environment (i.e. school, workplace)
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S CHEDULING
Location
Notification of team membersClient/familyTherapistsRTS/Dealer
Transportation to appointment
Coordination of equipmentSpecific cushions, backs, wheelchairs needed
REQUEST FOR CURRENT P HYSICIAN ORDERS
Physical Therapy Evaluation for Seating/Mobility
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_________________________________________________________________ THE EVALUATION
__________________________________________________________________
REVIEW OF INFORMATION
Pertinent demographic informationDiagnoses
Primary Primary diagnosis relating to present concerns (e.g. cerebral palsy with spastic
quadriplegia and scoliosis) Secondary
Additional pertinent diagnoses Functional or treatment diagnoses
Hemiplegia, etc. Abnormal posture Abnormal involuntary movement Gait abnormality
Specific dates of onset
PrognosisProgressContraindications/precautions affecting equipment use
Uncontrolled seizures Orthostatic hypotension Open skin areas
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Pertinent demographic information (contd)Pertinent medical/surgical history
Past hospitalizationsHistory of skin breakdownRelevant surgeries
Orthopaedic Skin flaps Bone shavings
Pertinent medicationsCurrent or past services
Date last seen by MD
Current therapy and emphasisReferral sourceReason for referralHeight, weight
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Subjective information Client, caregiver, referral source goals
General Expectations What type of equipment does the client want? What does the client want to be able to do? What are the client s priorities? What are the client s expectations of this evaluation?
Functional goalsVocational goalsRecreational/lifestyle/personal goals
Current problems
Level of satisfaction with equipmentLikes/dislikesBroken partsFunctional implications/deficiencies related to current equipmentService history
Pain/discomfortFunctional implicationsRelation to equipment
Past equipment experiencesSuccesses/failuresTolerance/willingness to changePast experience with RTS/Dealer
Recent changes in functionRelated or unrelated to equipment
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Subjective information (contd) Environmental issues
Home environment General accessibility
Levels of homeType of entrance/exitLayoutDimensions of smallest doorways, halls
Does current wheelchair fit through all doorways? Location (i.e. rural, suburban)
Work, school, other environments General accessibility Requirements
Caregiver Role Availability Abilities
Transportation Type of vehicle Method of loading of wheelchair Driver vs. passenger Type of tie-down system
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Subjective information (contd) Psychosocial issues
Lifestyle Passive Active, involved Risk taker
Activity level Daily routine Amount of time up in wheelchair during day Work School Day program Recreation/leisure
MotivationSupport systemCultural influencesFamily dynamics/involvement
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P HYSICAL EXAMINATION Strength/Motor Control
Gross motor control manual muscle testingFine motor controlQuality of movementCoordinationReaction time, ability to initiate or stop movementTone/spasticityReflex activityMovement patterns
Volitional
InvoluntaryFunctional use of extremities
Effect on mobility, posture
Range of Motion/FlexibilityTolerance of corrective forces/pressure Effect on mobility, posture
EnduranceCardiopulmonary
Shortness of breath At rest With activity (i.e. after propelling wheelchair 20 ft.)
Labored breathing At rest With activity
Vital capacity May change with provision of postural support
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Endurance (contd)Muscular
Ability to generate and sustain force
Ability to perform repetitive contractionsTolerance of sustained activity Wheelchair propulsion
General activity tolerance
Sensation
Pressure reliefTechnique
StandingConstant shifting/changing of positionWheelchair pushupsManual tilt/reclinePower tilt/recline
FrequencyEffectiveness
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PainLocationSeverityLength of time presentPossible causesFunctional implications
Balance/Postural ControlHead control
Ability to achieve and maintain midline position
Influence of tone, reflexesTrunk control
Sitting with/without external supportAbility to assume and maintain erect postureInfluences of tone, reflexes
Standing with/without external supportStatic sitting and standing balanceDynamic sitting and standing balanceFunctional implications
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Activities of Daily LivingTransfersFeedingBathingCommunicationDressingHygieneBowel/bladderHousehold/community activitiesAides/caregiversEmployment/educational activities
Assistance providedTime available
Implications of positioning, mobility
VisionAcuityNeglect
Blurred visionForward gazeDepth perceptionField lossesScanningPerceptual deficits
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CognitionAbility to follow directions (simple vs. complex)Attention spanJudgmentDistractibilityUnderstanding of cause/effectNeglectEffect on use of equipment
CommunicationAbility to communicate functionallyEffect of positioning on communication/interactionManagement of secretionsUse of augmentative communication device
Transport/mounting considerationsIntegration considerations
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EVALUATION OF CURRENT EQUIPMENT
Seating System (cushion, back, other supports)Manufacturer, modelAgeDimensionsConditionRepair historyEstimated cost of repairsEstimated remaining life expectancyComfort
Effect on positioning/pressure distributionPressure mappingAcceptability to useAppropriateness
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WheelchairManufacturer, modelAgeDimensionsComponents
Seat and back upholsteryArmrestsLegrestsFootplatesWheels/castersTires
ConditionEstimated cost of repairsEstimated remaining life expectancyComfort
Effect on positioning/pressure distribution Effect on mobility function
Acceptability to userAppropriateness
FitFunctionAccessibility
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S EATING /P OSITIONING ASSESSMENT
Basic Principles
Review of normal postural alignmentPelvis neutral (or slightly anterior) and symmetricalTrunk erect with slight lumbar and cervical lordosis, slight thoracic kyphosisThighs and legs separatedKnees and ankles flexed to 90 degrees, with feet resting on floor or support surfaceHead upright and in midlineShoulders and arms relaxed and supported
Characteristics of normal postureProvides stable base of support; stability precedes mobilityActive and dynamic
Dynamic posture is crucial for function in or out of a chair. Mobility is superimposed on an active, responsive base. Quality of posture determines motor skill capability. Motor function is the interplay between posture and movement. Ball 1996
Allows horizontal gaze and optimal visual fieldAllows optimal arm and hand functionPelvic position largely determines posture
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Examination of resting posture in Wheelchair/Seating SystemNote position of
PelvisTrunk/spineHead/neckHips/legsKneesAnkles/FeetShouldersArms
Observe and palpate symmetry of bony landmarksShoulders
Ability to self-correct or move into neutral alignmentPostural changes with volitional/non-volitional movement
Examination in supinePelvic mobilityLower extremity flexibilityRange of motionSpinal flexibility
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Examination in sitting at edge of matSitting balance/trunk control
How much effort is required to maintain this neutral posture with the influence of
gravity?Posture
Note posture under the influence of gravity as compared to that observed when sittingin current seating system
Pelvis Trunk/spine Head/neck Hips/legs Knees Ankles/Feet Shoulders Arms
Note postural changes with volitional/nonvolitional movementObserve and palpate symmetry of bony landmarksReevaluate flexibility of deviations observed in supineProvide support to correct flexible deviations, accommodate fixed deformities, andallow individual to maintain neutral posture.
Location of needed corrective support was indicated during supine assessment. May require additional support, or support in other areas when influenced by
gravity. May require change in orientation (i.e. tilt-in-space)
Begin thinking of what type of supports may be necessary to replicate the supportiveforce.
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MOBILITY ASSESSMENT
Primary means of mobility
AmbulationManual wheelchairPower wheelchairScooterOther
Dependently carriedCrawling, creeping
AmbulationLevel of independenceType of assistive device usedDistanceEfficiency/energy expenditureSafety
Need to hold on to walls, furnitureFrequency and severity of falls
Functional for home or other environmentsImpact on Mobility Related Activities of Daily Living
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Manual wheelchairLevel of independence
Propulsion techniqueArmsLegsOne armArm/leg combination
DistanceEfficiency/energy expenditure
Postural changes during propulsionObstacle managementPerformance/safety on varied terrain
Flat, level surfacesCarpetRamps/inclinesGrass
GravelManeuvering/managing wheelchair during transfers
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Manual wheelchair (contd)Advanced skills
Loading wheelchair into vehicleCurbsRampsStairsFallingRighting the wheelchairCushion adjustmentNarrowing the wheelchairWheeliesGlides in a wheelieTurning on a dime
Impact on Mobility Related Activities of Daily Living
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Power wheelchairLevel of independenceAccess point
HandHeadChin/mouthOther body part
Input deviceHand control/joystickHead control
Chin controlPneumatic/sip&puffSwitches
DistanceEfficiencyPostural changes during operationObstacle management
Performance/safety on varied terrainFlat, level surfacesCarpetRamps/inclinesGrassGravel
Maneuvering/managing wheelchair during transfers
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Scooter/Power Operated VehicleLevel of independenceType of controlDistanceEfficiencyPostural changes during operationObstacle managementPerformance/safety on varied terrain
Flat, level surfacesCarpet
Ramps/inclinesGrassGravel
Maneuvering/managing scooter/seat during transfers
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_________________________________________________________________ EQUIPMENT OPTIONS
__________________________________________________________________
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S EATING INTERVENTION
Forms of postural support
Spinal fixation (i.e. Harrington rods)Intimate support (i.e. body jacket, corset)Adaptive seating
Goals of adaptive seating Support neutral posture or posture required for function. - J. Zollars Provide sufficient external support to restore normal sitting posture without
restricting function, and to maximize pressure distribution to prevent tissue trauma.- J. Minkel
Obtain optimal postural alignment. M. Ball Provide postural support for symmetrical biomechanical alignment Correct or accommodate postural deformities Inhibit abnormal tone and reflexes to prevent abnormal postural alignment and
deformities Improve safety Improve respiratory function Provide pressure relief or reduction to prevent compromise of skin integrity Equalize pressure distribution Increase sitting tolerance to level sufficient for requirements of daily activities Improve interaction with other individuals and the environment Improve function in ADL, self-care, mobility, and communication Improve comfort
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Classification of Support SurfacesPrimary
Cushion/seatBack
SecondaryHeadrestFootrestArmrestPelvic/thigh supportsTrunk supportsShoulder supports
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TYPES OF P RIMARY S UPPORT S URFACES (CUSHIONS /B ACKS )
Fluid/Flotation
AirContains one or multiple air bladders or cellsAdvantages
Excellent pressure relief Lightweight Easy to clean Air may flow between cells
Disadvantages High maintenance Poor durability May make transfers difficult
WaterSealed cushion with waterbased fluid insideNot a frequently used type of cushionAdvantages
Good pressure relief Reduces shearing Dissipates heat well
Disadvantages Heavy Assumes ambient temperature
CAN FREEZE CAN GET VERY HOT
May make transfers difficult
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Fluid/Flotation Cushions/Backs (contd) Viscous fluid
Gels or fluids contained in oversized flexible membranesTypically used in combination with some type of foam base/shellAdvantages
Good pressure relief Reduces shearing Easy to clean Dissipates heat well
Maintains fairly stable temperatureDisadvantages
Heavy Can be uncomfortable if sensation is intact May make transfers difficult
Elastomer gelFirm gel contained in flexible membranes (similar to Jello)Typically used in combination with some type of foam base/shellAdvantages
Dissipates heat well Maintains fairly stable temperature Reduces shearing
Disadvantages Poor durability Difficulty attaching to foam surface
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PolyfoamsPlanar
Flat surface, typically plywood covered with foam and upholstery.
Advantages Adjustable (i.e. for growth) Modular components Available from many manufacturers Offers minimal support Accommodates a wide variety of postures Lightweight Inexpensive Easiest to maintain Least interference with transfers
Disadvantages No pressure relieving properties Often result in localized pressure over bony prominences, with greater risk of
shearing forces developing under weighted areas Least surface contact Provide least support for maintaining neutral posture
Typical applications Good pelvic and trunk control Frequent changes in position Pediatric clients Progressive disabilities Short periods of sitting
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Polyfoams (contd) Contoured
Commercially fabricated contoured surface of predetermined size and shape basedupon anthropomorphic data. Typically a combination of molded plastic shell andcontoured foam, occasionally with pressure relieving gel or air inserts.Advantages
Pre-contoured for a generic body type Offers moderate support Greater pressure distribution Reduces risk of peak pressures under weighted soft tissues More forgiving than an intimately contoured surface Some adjustability
Disadvantages Offers minimal postural accommodation Not contoured to an individual s shape May have to add accessories to achieve adequate support May restrict postural adjustments
Components typically require constant monitoring to insure proper placement May require some maintenance
Typical Applications Fair trunk control and balance Specific body types and postural deformities compatible with specific products Need for pressure reduction or equalized pressure distribution Need for portability
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Polyfoams (contd) Molded
Contoured surface created to fit the exact contours of a single user.Advantages
Offers maximum support Best pressure distribution Best accommodation of deformities Individualized shape Least peak pressures and shear
Disadvantages Requires skilled clinician and supplier Reduced air flow between support surface and skin Total support may prevent development or improvement of postural control Restriction of movement prevents postural adjustments and weight shifting Minimal adjustability Labor intensive and costly
Typical Applications
Poor trunk control and balance Severe fixed deformities
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OscillatingContain air cells that alternately inflate and deflate, or alternately change mechanicalpressure.Advantages
Excellent pressure reduction, possibly promoting healing of open areas while allowingfor limited sitting time.
DisadvantagesVery costly
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TYPES OF S ECONDARY S UPPORT S URFACES (ACCESSORIES )
Pelvic and thigh control components
Medial thigh supportsLateral thigh supportsLateral pelvic supportsAnterior pelvic supports
ASIS pads/bar pelvic positionerPelvic beltSafety belt
Trunk control componentsLateral thoracic supportsPosterior lumbar supportsSacral supportsAnterior trunk support
Shoulder control componentsPosterior shoulder supportsAnterior shoulder supportsSuperior shoulder supports
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Head/neck control componentsPosterior neck supportPosterior head supportLateral head supportAnterior head supportCircumferential head/neck support (i.e. cervical collar)
Upper extremity control componentsArm supportArm troughTray
Provides support to the arms and upper extremities; can be used to assist upper trunkor arm positioning.
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Lower extremity control componentsPosterior calf support
Calf strapCalf pad
Foot supportFoot platform one pieceFootplates individual
Fixed angle Angle adjustable
Foot positioner Heel loops Ankle straps Toe straps Shoe holders
Anterior knee supportAnterior leg support
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DYNAMIC P RESSURE RELIEVING S EATING S YSTEMS
Tiltinspace
Seat-back angle is maintained as the seating system rotates around a fixed or slidingpivot point.
Typically tilt in a posterior direction to re-distribute and relieve pressure.
May also be used to provide rest from the upright position, and gravity assistedpositioning to improve posture and head control.
Manual Power Posterior tilt Anterior tilt Lateral tilt
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ReclineSeat-back angle to increase as the backposts are reclined.
Typically used for accommodation of severe hip extension contractures, orthostatichypotension, and pressure re-distribution for prevention of skin breakdown.
May result in tendency to slide forward in the seat.
May cause shearing at the sacrum and low back.
Manual Power Low Shear
StandersManual or power systems which move from the seated to standing positions.
Typically used for environmental access and pressure relief.
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MOBILITY INTERVENTION
Goals of Wheeled Mobility Provide a means of independent mobility Maximize performance of activities of daily living Allow access to all terrain and environments encountered during the course of the
day Provide support of neutral posture Provide orientation in space required for optimal posture and function Provide a base for the adaptive seating system Provide a means of pressure relief
Accommodate changes in size and weight
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TYPES OF MOBILITY BASES
Dependent mobility bases
StrollersTypically used for dependent community mobility for childrenSome models have higher weight limits suitable for small adultsVariety of seating options
Transport wheelchairs
Lightweight chair with small wheels used for dependent transportation over levelsurfacesVery few options
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Manual wheelchairsStandard
Medicare classification (K0001)
Traditional wheelchair with no adjustability and very few optionsVery heavy, requiring good strength and sitting balance to operate effectivelyVery durableFew options
Standard hemiMedicare classification (K0002)Traditional wheelchair with a lower seat heightAllows for propulsion with feet
Few optionsLightweight
Medicare classification (K0003)Similar in appearance to traditional wheelchair, but slightly lighter weightMay have some axle adjustability.Beneficial for individuals with slight upper extremity weaknessFew options
High-strength lightweight
Medicare classification (K0004)Lightweight wheelchair of durable constructionLimited axle adjustability; may have 1 or 2 positions, or some horizontal or verticaladjustabilityVariety of components available as optionsMost models have hemi optionSome models offer onearm drive mechanism
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Manual wheelchairs (contd) Ultra-lightweight
Medicare classification (K0005)Greatest degree of adjustability maximize user efficiency and functionAxle adjustability allows center of gravity of the user to be changed in relation to thewheel basePreviously used by high functioning usersFrequently used by individuals with severe weakness, fatigue, or complex positioningrequirements due to ability to maximize efficiency
Folding frames Traditional cross-brace frame Offers greatest ease of folding Greater shock absorbancy Can be narrowed to get through doorways Can be grown by replacing cross tubes and upholstery Less efficient propulsion
Rigid One-piece frame, typically with horizontal cross bars Offers greater durability Lighter weight Offers more efficient ride Less shock absorbancy May be difficult for some individuals to fold
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Heavy-dutyMedicare classification (K0006)Traditional wheelchair with no or limited adjustabilityDurable construction for users weighing more than 250#Very few optionsVery heavy
Extra Heavy-dutyMedicare classification (K0007)Traditional wheelchair with no or limited adjustabilityDurable construction for users weighing more than 300# Very few optionsVery heavy
CustomMedicare definition (K0008)
Uniquely constructed or modified for the specific beneficiary Feature needed not available on an already manufactured base Must be customization of the frame, not components
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Wheelchair ComponentrySeat
UpholsteryNYLON NAUGAHYDE
Solid Adjustable angle
Back Upholstery
NYLON NAUGAHYDE ADJUSTABLE TENSION
Can accommodate slight postural deviations
Can be kept tight to prevent sling over time Back-posts
S TRAIGHT BACK -POSTS 8-10 DEGREE BEND ADJUSTABLE ANGLE P USH HANDLES
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Legrests Select based upon functional need
ALLOW FOR TRANSFERS ACCOMMODATE KNEE CONTRACTURES REDUCE EDEMA REDUCTION OF SPASTICITY /TONE
Swing-awayEASIEST TO REMOVE FOR TRANSFERS CAN BE REMOVED TO INCREASE ACCESSIBILITY MECHANISM MAY BE DIFFICULT TO MANEUVER , AND MAY WEAR -OUT WITH TIME
Rigid/fixedGREATER DURABILITY MAY MAKE TRANSFERS DIFFICULT CANNOT REMOVE TO IMPROVE ACCESSIBILITY
Semi-rigidS WING -AWAY LEGRESTS JOINED TOGETHER AT THE FOOTPLATE IMPROVES DURABILITY
ElevatingUSEFUL IN CASES OF LIMITED ROM, EDEMA INCREASES OVERALL CHAIR LENGTH MAY COMPROMISE PELVIC POSITION BY STRETCHING HAMSTRINGS QUESTIONABLE BENEFIT FOR EDEMA REDUCTION INCREASES LENGTH OF CHAIR , DECREASES ACCESSIBILITY MECHANISM DIFFICULT TO OPERATE
ArticulatingLEGRESTS EXTENDS AS IT ELEVATES , ALLOWING TRUE ELEVATION WITHOUT CAUSINGTHE KNEE TO FLEX
TaperedINCREASED ACCESSIBILITY IMPROVED LEG ALIGNMENT DECREASED CALF SPACE
Hanger angle
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Footplates Composite or Aluminum Flip-up Extended Platform Angle adjustable Tubular High-mount
Armrests Selection based upon how used by individual
S TABILIZATION OF TRUNK S TABILIZING POINT FOR PUSHING UP TO STAND OR FOR PRESSURE RELIEF ATTACHMENT POINT FOR TRAY
Fixed Height
Adjustable height Removable vs. Flip-back Tubular/swing-away Desk length vs. full length
Axle Non-adjustable/single position Semi-adjustable Adjustable/multi-position Amputee/extended Quick release
ALLOWS REMOVAL OF REAR WHEELS REQUIRES GOOD HAND FUNCTION
Quad releaseALLOWS PERSON WITH LIMITED HAND FUNCTION TO REMOVE REAR WHEELS MAY ACCIDENTALLY DISENGAGE
One-arm drive
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Wheels Spoke Mag Composite
Tires Diameter and composition affect rolling resistance Solid/polyurethane
GOOD FOR INDOOR USE NO MAINTENANCE DURABLE ROUGH RIDE OUTDOORS HEAVY HIGH OR LOW PROFILE
High profile offers some traction
PneumaticLESS ROLLING RESISTANCE GOOD ON ROUGH TERRAIN GOOD TRACTION LIGHTWEIGHT AIR PRESSURE MUST BE MAINTAINED FOR PERFORMANCE
Airless/foam insertsMAKES PNEUMATIC TIRES FLAT -FREE ADDS WEIGHT
Kevlar
REINFORCED
,PUNCTURE RESISTANT TIRE
KnobbyALL TERRAIN TIRE WITH SIGNIFICANT TREAD INCREASED TRACTION P UNCTURE RESISTANT
High-pressureHIGH PERFORMANCE LIGHTWEIGHT REQUIRES PRESTA VALVE (SMALL BICYCLE -TYPE VALVE )
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Handrims Anodized aluminum/chrome Plastic coated Molded Projections
Wheel locks Push-to-lock Pull-to-lock Scissor High-mount Low-mount
Casters Small front wheels attached to fork, swivels about stem bolt Large casters (6-8)
LEAST ROLLING RESISTANCE IMPROVED MANEUVERABILITY OVER UNEVEN TERRAIN INCREASED CLEARANCE BETWEEN FOOTPLATE AND GROUND CAN BE USED TO ACHIEVE POSTERIOR TILT -IN-SPACE
Small casters (3-5)MORE RESPONSIVE TO QUICK TURNS AID IN CURB MANEUVERABILITY INCREASED CLEARANCE BETWEEN FOOTPLATE AND CASTER LESS SHIMMY (SIDE -TO -SIDE FLUTTER AT HIGH SPEEDS )GREATER ROLLING RESISTANCE DECREASED ABILITY TO ROLL OVER OBSTACLES
SolidNO MAINTENANCE LEAST ROLLING RESISTANCE
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Casters (contd)
PneumaticMOST SHOCK ABSORPTION OFFER SMOOTHER RIDE EASE OF MANEUVERING OVER UNEVEN SURFACES
Semi-pneumaticNO MAINTENANCE COMPROMISE BETWEEN ABOVE
Caster stem boltLONG STEM BOLT IMPROVES CLEARANCE BETWEEN FOOTPLATE AND FLOOR INCREASES TILT WITHOUT CHANGING CASTER
Caster forkLONGER FORK INCREASES TILT WITHOUT CHANGING CASTER DECREASES CLEARANCE BETWEEN HEEL AND CASTER
Quick release castersUSEFUL FOR THOSE WHO EXCHANGE FRONT CASTERS FOR DIFFERENT ACTIVITIES
Caster pin locksP ROVIDE ADDITIONAL STABILITY OF WHEELCHAIR DURING TRANSFERS DIFFICULT TO MANAGE
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Accessories Anti-tippers
MAY INTERFERE WITH NEGOTIATION OF ROUGH TERRAIN ; DECREASES GROUNDCLEARANCE
REAR
FRONT Brake extensions
BRAKE IS EASIER TO REACH AND ENGAGE USEFUL FOR HEMIPLEGICS DECREASE BRAKE DURABILITY MAY INTERFERE WITH TRANSFERS AND PROPULSION
Grade aidsP REVENTS WHEELCHAIR FROM ROLLING BACKWARD WHEN ASCENDING INCLINES MUST BE USED ON TIRE WITH TREADS (I.E. PNEUMATIC )DIFFICULT TO PROPEL WHEN ENGAGED MAY ENGAGE INADVERTENTLY MAY PREVENT RECOVERY FROM BACKWARD FALL P OOR DURABILITY
Clothing guardsP REVENT HIPS AND THIGHS FROM RUBBING TIRES CAN BE USED TO CENTER CUSHION OR PERSON IN SEAT
R IGID Must remove for lateral transfersLimit use of larger cushion if increased width needed
CLOTH Does not need to be removed for transfersAllows for use of wider cushion if necessaryNeeds to be tightenedAllows for slipping of cushion
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Accessories (contd)
Spoke guardsP ROTECTS FINGERS FROM INJURY
PREVENTS DAMAGE TO SPOKES
MAY NEED TO REMOVE IN ORDER TO TIE -DOWN IN VEHICLE MAY RATTLE IF NOT TIGHT
Leg straps/heel loopsMAINTAIN FOOT POSITION MAY BE USEFUL DURING TRANSFERS BETWEEN CHAIR AND FLOOR MAY MAKE TRANSFERS DIFFICULT
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TYPES OF MOBILITY BASES (CONT D)
Scooters/Power Operated VehiclesTypically steered with a tillerSpeed is controlled by thumb leverTypically used for community mobility by individuals with limited ambulatory functionThree-wheeled
Narrow base of supportHigh center of gravityUnstable
Requires good trunk control and good upper extremity functionLarge turning radius
Four-wheeledMore stableRequires good trunk control and good upper extremity function
Large turning radius
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Power Wheelchairs (contd) All Group 2 PWC; K0820 K0843
Standard integrated or remote proportional joystick May have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions, headrests, lateral trunk supports, lateral hip supports, medial thigh supports) (except captains chairs) Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 3 MPH Minimum Range - 7 miles Minimum Obstacle Climb - 40 mm Dynamic Stability Incline - 6 degrees
Group 2 No Power Options PWC; K0820 K0829 Non-expandable controller Incapable upgrade to expandable controller Incapable of upgrade to alternative control devices Incapable of accommodating a power tilt, recline, seat elevation, standing system Accommodates non-powered options and seating systems (e.g., recline-only
backs, manually elevating legrests) (except captains chairs)
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Power Wheelchairs (contd)
All Group 3 PWC; K0848 K0864 Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices May not have crossbrace construction Accommodates seating and positioning items (e.g., seat and back cushions,
headrests, lateral trunk supports, lateral hip supports, medial thigh supports)(except captains chairs)
All Group 3 PWC; K0848 K0864 (2) Additional requirements: Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4.5 MPH Minimum Range - 12 miles
Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 7.5 degrees
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Power Wheelchairs (contd) Group 4 PWCs K0868 K0886
Have added capabilities not needed for home use If provided and coverage guidelines met for Group 2 or 3, allowance based on least
costly alternative medically appropriate PWC If billed with KX modifier, allowance based on comparable group 3 PWC
Group 5 PWC; K0890 K0891 Standard integrated or remote proportional joystick Non-expandable controller Capable of upgrade to expandable controller Capable of upgrade to alternative control devices Seat Width: minimum of 5 one-inch options Seat Depth: minimum of 3 one-inch options Seat Height: adjustment requirements- 3 inches Back Height: adjustment requirements minimum of 3 options Seat to Back Angle: range of adjustment-minimum of 12 degrees Accommodates non-powered options and seating systems
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Power Wheelchairs (contd) Group 5 PWC; K0890 K0891 (2)
Additional requirements: Accommodates seating and positioning items (e.g., seat and back cushions,
headrests, lateral trunk supports, lateral hip supports, medial thigh supports) Adjustability for growth (minimum of 3 inches for width, depth and back height
adjustment) Special developmental capability (i.e., seat to floor, standing, etc.) Drive wheel suspension to reduce vibration Length - less than or equal to 48 inches Width - less than or equal to 34 inches Minimum Top End Speed - 4 MPH Minimum Range - 12 miles Minimum Obstacle Climb - 60 mm Dynamic Stability Incline - 9 degrees Crash testing - Passed
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Power Wheelchairs (contd)
Power seating optionsDynamic pressure relieving seating system
Power tiltS EAT -BACK ANGLE MAINTAINED AS SEATING SYSTEM ROTATES AROUND A FIXED ORSLIDING PIVOT POINT MAINTAINS SITTING POSTURE WHILE ORIENTATION TO GRAVITY IS CHANGED TYPICALLY REQUIRES A LONGER , HEAVY BASE NEW FORWARD SLIDING SYSTEMS ALLOW USE OF SHORT BASE
Power reclineS EAT -BACK ANGLE INCREASES AS THE BACK -POSTS ARE RECLINEDTYPICALLY REQUIRES A LONGER , HEAVIER BASE MAY INCLUDE SELF -ELEVATING LEGRESTS (AUTOMATICALLY ELEVATE AS BACKRECLINES )
Power standS EATING SYSTEM MOVES FROM SITTING TO STANDING ALLOWS INDIVIDUAL TO COME TO A STANDING POSITION FOR ADLS MAY OR MAY NOT BE ABLE TO BE DRIVEN IN STANDING POSITION
Power elevating seatS EATING SYSTEM IS RAISED OR LOWEREDALLOWS FUNCTIONAL HEIGHT FOR ADLS , TRANSFERS , INTERACTION WITH OTHERS
Power elevating legrestsLEGRESTS ELEVATE EXCLUSIVE OF THE SEATING SYSTEM ALLOWS INDEPENDENT LOWER EXTREMITY ELEVATION FOR EDEMA REDUCTION ORPOSITIONING
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Power wheelchair componentsInput devices
Allow user to input the speed, direction, and command to stop the wheelchair Proportional
DIRECTION AND SPEED OF THE CHAIR ARE IN PROPORTION TO AMOUNT OF MOVEMENTAT THE INPUT DEVICE J OYSTICK
Hand controlChin controlHead controlled joystick
P EACHTREE HEAD CONTROL Digital
S WITCHES ARE EITHER ON OR OFF NON -PROPORTIONAL BODY /CONTACT SWITCHES
Switch activated by direct pressureEach switch controls a direction or functionMay be used at nearly any access point, in any combination
P ROXIMITY /NON -CONTACT SWITCHES Switch activated by movement toward or away from the switch
Each switch controls a direction or functionMay be used at nearly any access point, in any combinationP NEUMATIC (SIP &PUFF )
Motors Allow movement of the chair Belt or direct drive Mounted to front, mid, or rear wheels
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Controller Brain of the wheelchair Allows adjustment of parameters (how wheelchair responds to input from the user)
MAXIMUM SPEED
LOW SPEED ACCELERATION DECELERATION TURNING SPEED TREMOR DAMPENING
Also called sensitivityMakes wheelchair more or less responsive to joystick movementUseful in cases of tremor or extraneous movement
J OYSTICK THROW Amount of joystick movement necessary to obtain full speed and directioncontrolOften reduced for users with limited ROM
MOMENTARY CONTROL Chair operates as long as input is providedChair stopped when no input
LATCHED CONTROL Either on or offChair operates continuously in response to single activation of switchSubsequent activation of switch stops movement
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INTEGRATION ISSUES Tilt/recline systems
Compatibility with various manufacturers
Variations in tilt systemsBasic tiltCenter of gravity tiltForward sliding/weight shifting tilt
Additional seat heightAttachment of after-market backsPinch pointsDrive lock-out
Transportation issuesTie-down systemLift/loadingTransfersDriving
Alternative methods of accessCompatible electronicsSufficient access sites for all devices
Communication devices/computer accessCompatible electronicsMounting of system to wheelchairPlacement of cablesSeat height
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OTHER MOBILITY DEVICES
Pushrim activated power assist
Attach to manual wheelchair framesMotor turns rear wheelsAllows use of wheelchair as manual or powerWeight negatively affects use as manual wheelchairEasily removed to allow folding of wheelchair for transport
Beach wheelchairs
Handcycles
Sports wheelchairs
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_________________________________________________________________ TRIALS
_________________________________________________________________ Start with least expensive mobility option that may meet their mobility and positioningneeds
Wheelchair Wheelchair componentry
Add least expensive seating intervention that will provide amount of support deemednecessary from the mat assessment
Primary support surfaces Secondary support surfaces
Attempt to match the individual s dimensions as closely as possible
Assess for each option evaluated: Fit Comfort Positioning Mobility Transfers Functional abilities
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_________________________________________________________________
TRIALS (cont d) _________________________________________________________________
Determine effectiveness of least costly options, noting reasons why they did or notwork
Progress to other mobility and seating options, concluding when you have determinedthe least costly option that will meet the individual s mobility, positioning, comfort, and
functional needs.
If no objective or subjective difference between options, chose the least costly option.
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_________________________________________________________________
EQUIPMENT SPECIFICATION _________________________________________________________________
While positioned in the least costly, most appropriate intervention, verifythe individuals measurements in the context of the equipment
Collaborate with the client and RTS/dealer to
Determine appropriate equipment dimensionsComplete wheelchair and seating system order formsSpecify all componentsSpecify type and size of primary support surfacesSpecify type and size of secondary support surfacesEnsure client s understanding of all options specified
Incorporate info from Vendor home assessment
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_________________________________________________________________
CASE STUDIES _________________________________________________________________
ManualC7 complete tetraplegia50 woman with hemiplegiaBilateral LE amputeeDecreased visionMS, limited ambulation, impaired coordination400 poundsTriplegia (i.e. only left arm function)Profound MR, severe scoliosis, pelvic obliquityPoor judgmentInability to perform pressure reliefsClient drives own car
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_________________________________________________________________ CASE STUDIES
_________________________________________________________________
PowerCOPD, oxygen dependentSevere trunk and UE ataxiaC4 complete tetraplegiaExtreme startle reflexesImpaired vision
400 poundsInability to perform pressure reliefsDistractibility, poor judgmentRapidly progressing ALSUse of public transportationClient drives own van
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_________________________________________________________________ FUNDING AND DOCUMENTATION
_________________________________________________________________
THE OLD DAYS :
Medically NecessaryDurable Medical Equipment is required for the treatment of the client s documentedmedical condition
Prescribed by a PhysicianPhysician attests to the documented medical need of the covered device.
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EVOLUTION OF MEDICARE COVERAGE
Typically covers older adults or people with long term disabilities
Policies largely determine industrywide reimbursementCoverage Considerations:
Medicare is a defined benefit program.An item or service must fall within one or more benefit categories, and not otherwisebe excluded by statute from coverage. Section 1861(n) of the Social Security Act listsitems that are included as durable medical equipment (DME), including wheelchairs.MAE is covered under the benefit category of DME. DME is defined as equipment that
1) can withstand repeated use,2) is primarily and customarily used to serve a medical purpose,3) generally is not useful to an individual in the absence of an illness or injury, and4) is appropriate for use in the home (42 C.F.R. 414.202).
CMS has several national coverage determinations (NCD) regarding various mobilityassistive equipment.
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Recent EventsExcerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment(CAG-00274N)
On December 15, 2004, CMS opened an NCD on mobility assistive equipment toexamine and set the clinical criteria for the provision of this equipment.Recent allegations of wheelchair fraud and abuse have focused considerable publicinterest on the provision of wheelchairs under the Medicare benefit. The agency hasresponded with a multifaceted plan to ensure the appropriate prescription ofwheelchairs to beneficiaries who need them. One facet of this plan is thedelineationof suggested clinical conditions of wheelchair coverage .
Many advocacy groups have suggested that the agency adopt a functionbasedinterpretation of its historicalbed or chair confined criterion for wheelchaircoverage.
Historically, wheelchairs have been covered if [the] patient's condition is such thatwithout the use of a wheelchair he would otherwise be bed or chair confined. Anindividual may qualify for a wheelchair and still be considered bed confined.
Wheelchairs (power operated) and wheelchairs with other special features are coveredif [the] patient's condition is such that a wheelchair is medically necessary and thepatient is unable to operate the wheelchair manually.
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In June of 2004, CMS formed a workgroup (the Interagency Wheelchair Work GroupIWWG) of Federal employees to review its current policy for wheelchair provision andto analyze the published scientific literature on the use of wheelchairs. The IWWGmade several recommendations for the clinical interpretation of CMS statutory,
regulatory and clinical guidelines, including the adoption of a functionbaseddetermination of medical necessity. A functionbased determination might considerthe beneficiarys inability to safely accomplish activities of daily living, such astoileting, feeding, dressing, grooming, and bathing with and without the use ofmobility equipment, such as a wheelchair.
On December 15, 2004, CMS initiated the national coverage determination to addressthe appropriate prescription of Mobility Assistive Equipment.
Consistent with IWWG recommendations and our internal review, CMS chose to useactivities of daily living such as toileting, feeding, dressing, grooming, and bathing asthese are activities necessary to serve a medical purpose in the home. We collectivelynamed these mobility related activities of daily living (MRADLs).
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RESULTING RECOMMENDATIONS FOR ASSESSMENT /P RESCRIPTION Excerpted from May 5, 2005 CMS Decision Memo for Mobility Assistive Equipment(CAG-00274N)
Appropriate Prescription of Mobility EquipmentAn assessment of the beneficiary s physical, cognitive, and emotional limitations andabilities, willingness to use mobility assistive equipment on a routine basis, and thebeneficiary s typical home environment is recommended to determine the appropriateprescription of mobility equipment.
In order to facilitate the application of the new functional criteria, the IWWG proposedthe following suggestions for the provision of wheelchairs.
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Provision of Mobility Assistive Equipment Under Medicare Should IncludeAll Five Points Below
The beneficiary s physical limitations (diminished strength, speed, endurance, rangeof motion, coordination, sensation, deformity) prevent the beneficiary fromaccomplishing mobility-related activities of daily living in the home.
The beneficiary s mental capabilities (cognition, orientation, communication, judgment, memory, comprehension, affect, and suitable behavior) are sufficient forsafe and adequate performance of mobility-related activities of daily living with the useof mobility assistive equipment.
The beneficiary s physical capabilities (strength, speed, endurance, range of motion,
coordination, sensation) are sufficient for safe and adequate performance of mobility-related activities of daily living with the use of a mobility assistive equipment.
The characteristics of the beneficiary s typical home environment in which theactivities of daily living are encountered (surfaces, presence or absence of surfaceaccommodations, obstacles, accessibility, changes in grade, and distances covered)are suitable for use of the appropriate equipment.
The beneficiary demonstrates willingness to use the equipment routinely.
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Clinical Criteria for Wheelchair PrescribingThe beneficiary, the beneficiary s family or other caregiver, or a clinician will usuallyinitiate the discussion and consideration of wheelchair use.
Sequential consideration of the questions below provides clinical guidance for theprescription of a device of appropriate type and complexity to restore the beneficiary sability to perform mobility-related activities of daily living.
These questions correspond to the numbered decision points on the accompanyingflow chart.
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#1: Mobility limitation?
Clinical Criteria Algorithm for Wheelchair Prescribing
Request initiated for mobilitydevice for willing patient
#5: Canes/walkers?
#2: Other limitations?
#8: POV?
#3: Compensated?
Exit
No
Yes
Yes
No
# 6: Environment ?
#7: Self-propel?
#4: Capable of safe use?
Safe?
#9: PWC appropriate? Power wheelchair
Appropriatemanual
wheelchair configuration
POV
Canes
or walkers
Yes Yes
No
Yes
No
No
No
Safe?
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Safe?
Safe?
No
Yes
No
No
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Does the beneficiary have a mobility limitation causing an inability to perform one ormore mobilityrelated activities of daily living in the home? A mobility limitation is onethat
Prevents the beneficiary from accomplishing the mobility-related activities of dailyliving entirely, or
Places the beneficiary at reasonably determined heightened risk of morbidity ormortality secondary to the attempts to perform mobility-related activities of dailyliving, or
Prevents the beneficiary from completing the mobility-related activities of dailyliving within a reasonable time frame.
Are there other conditions that limit the beneficiarys ability to perform mobility
related activities of daily living at home? Some examples are significant impairment of cognition or judgment and/or vision. For these beneficiaries, the provision of a wheelchair might not enable them to
perform mobility-related activities of daily living if the comorbidity prevents effectiveuse of the MAE or reasonable completion of the tasks even with a wheelchair.
If these other limitations exist, can they be ameliorated or compensated sufficientlysuch that the additional provision of a mobility equipment will be reasonablyexpected to materially improve the beneficiary s ability to perform mobility-relatedactivities of daily living in the home?
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Does the beneficiary demonstrate the capability and the willingness to consistentlyoperate the device safely?
Safety considerations include personal risk to the beneficiary as well as risk toothers.
The determination of safety may need to occur several times during the process asthe consideration focuses on a specific device.
A history of unsafe behavior in other venues may be considered.
Can the functional mobility deficit be sufficiently resolved by the prescription of a caneor walker?
The cane or walker should be appropriately fitted to the beneficiary for thisevaluation.
Assess the beneficiary s ability to safely use a cane or walker.
Does the beneficiarys typical environment support the use of wheelchairs orscooters/POVs?
Determine whether the beneficiary s environment will support the use of thesemobility assistive equipment.
Keep in mind such factors as temperature, physical layout, surfaces, andobstacles, which may render an item of mobility assistive equipment unusable inthe beneficiary s home.
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Does the beneficiary have sufficient upper extremity function to propel a manualwheelchair in the home through the course of the performance of mobilityrelatedactivities of daily living during a typical day?
The manual wheelchair should be optimally configured (seating options,wheelbase, device weight and other appropriate accessories) for thisdetermination.
Limitations of strength, endurance, range of motion, coordination and absence ordeformity in one or both upper extremities are relevant.
A beneficiary with sufficient upper extremity function may qualify for a manualwheelchair. The appropriate type of manual wheelchair, i.e. light weight, powerassisted, etc. should be determined based on the beneficiary s physicalcharacteristics and anticipated intensity of use.
The beneficiary s home should provide adequate access, maneuvering space andsurfaces for the operation of a manual wheelchair.
Assess the beneficiary s ability to safely use a manual wheelchair.
Does the beneficiary have sufficient strength and postural stability to operate a poweroperated vehicle (POV/scooter)?
A POV is a 3 or 4-wheeled device with tiller steering and limited seat modificationcapabilities. The beneficiary must be able to maintain stability and position foradequate operation.
The beneficiary's home should provide adequate access, maneuvering space andterrain for the operation of a POV.
Assess the beneficiary s ability to safely use a POV/scooter.
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Are the additional features provided by a power wheelchair needed to allow thebeneficiary to perform one or more mobilityrelated activities of daily living?
These devices are typically controlled by a joystick or alternative input device, andcan accommodate a variety of seating needs.
The beneficiary's home should provide adequate access, maneuvering space andterrain for the operation of a power wheelchair.
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Specific Documentation Requirements for Each Category of MAE
See Noridian Documentation checklists (appendix) Manual wheelchairs Power wheelchair: Group 1/Group 2, no power options Power wheelchair: Group 2 Single/Multiple power options Power wheelchair: Group 3 Single/Multiple power options Power wheelchair: Group 3 No power options POV and Push-rim Activated Power Assist Device
See Noridian Power Wheelchair Documentation Requirements (appendix)
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OTHER P AYORS
Medicaid
Coverage based upon income; low-income and disabledMedicaid requires pre-authorization on certain items; this provides client anddealer/supplier with verification of coverage prior to ordering
DME must be medically necessary; intended for use in home environment
Requires specific medical justification for different types of DME
Payor of last resort; must go through other sources first
Covers DME at allowable charge (payment made to supplier/dealer); opportunity forindividual considerationCovers repairs
Covers DME for people in skilled nursing facilities through MAP 122 process
Coordinated by nursing facility social worker
Supplier/dealer must be willing to accept MAP 122 assignment (small monthlypayments over an extended time period)
DME for people in intermediate care facility, personal care homes, and adult homes ishandled through normal process
DME is owned by the client
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Commercial InsuranceCovers individuals under employers group plan, responsible for paying their portion ofthe premium
Also may be Medicare Supplemental planCoverage handbook typically offers vague summary of items covered
Most offer pre-authorization
DME must be medically necessary
Most require specific medical justification for DME, some require MD prescription orletter only
May require use of a participating supplier/dealer
Covers DME at certain percentage (i.e. 80%) of a reasonable" allowable charge;often subject to a small cap
The supplier/dealer will bill the remaining percentage of the balance (i.e. 20%) to thesecondary insurance or to the client
Some cover repairs
Most do not cover DME for people in skilled nursing facilities
DME for people in intermediate care facility, personal care homes, and adult homes ishandled through normal process
DME is owned by the client
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Workers CompensationCovers individuals with work-related injuries
Typically offers pre-authorization, but must be coordinated through case manager
Equipment must be medically, vocationally, or functionally necessary (broad definitionof what is acceptable)
Most require some level of justification for equipment; some may required MDprescription for certain items
May require use of a participating supplier/dealer
Covers equipment at 100%, but may obtain bids from several suppliers/dealers
Covers repairs
Equipment is owned by client
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Division of Vocational RehabilitationCovers individuals with an intent to return to work or schoolTypically offers pre-authorization, but must be coordinated through field counselor
Equipment typically must be vocationally necessary, but often cover items medicallyor functionally necessary (broad definition of what is acceptable)Requires written justification of need for equipmentMay require use of a contract supplier/dealerCovers equipment at 100%, but must often obtain bids from several suppliers/dealersCovers repairsEquipment is owned by DVR
Other SourcesDepartment of Veterans Affairs
Self-payPublic SchoolsDepartment of the Visually HandicappedCommunity Service FundCommunity Service BoardPhilanthropic organizationsChurchesPrivate/community fund raising
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DOCUMENTATION
Equipment Specifications/Quote
Therapist Evaluation Report / Letter of Medical NecessityPhysician Prescription
Medicaid: Certificate of Medical Necessity
Medicare: (see Noridian checklists)7 point physician prescription
Face-to-face examination by physicianPhysician chart notes
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_________________________________________________________________
DELIVERY AND FOLLOW-UP_________________________________________________________________
FITTING
Collaborate with the RTS/dealer to ensure that all equipment is asrecommended and configured appropriately prior to scheduling delivery
Attach primary and, if possible, secondary support surfaces to mobility baseprior to client arrival
A
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ADJUSTMENTS
With client positioned in seating/mobility system, ensure that allequipment is adjusted properly
Cushion positionBack positionArmrest heightLegrest positionSecondary supports
Headrest Lateral supports Pelvic positioning belts
Controls/switches
Securely attach all equipment once final position is achieved
Reassess seating/mobility system for:FitComfortPositioningMobilityTransfersFunctional abilities
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TRAINING
Make sure client/family/caregiver is able to position client properly inseating/mobility system
Make sure client/family/caregiver is able to disassemble/ reassemble andadjust all necessary parts
LegrestsArmrestsCushionBack
WheelsOn/offAir pressure
Folding/loading wheelchair for transportCharging wheelchair batteries
Recommend therapy program for additional mobility training if necessary
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EDUCATION
Warranty information
Care of equipmentRepairsCleaning
Contact person for additional questions/concerns regardingseating/mobility system (usually RTS/dealer)
FOLLOW -UP
Encourage coordination of equipment issues directly with RTS/dealer
Provide client with therapist contact information should any issues arisethat are beyond the scope of the RTS/dealer
Phone followup at regular intervals is strongly encouraged
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_________________________________________________________________
REFERENCES _________________________________________________________________
Ball, M. (1996) A Multidisciplinary Approach to Dynamic Seating of the MultiplyInvolved Client. Conference sponsored by Freedom Designs, Charlotte, NC.
Center for Assistive Rehabilitation Technology Training and Evaluation (CARTE),Central Region Training Manual (1996). Virginia Department of RehabilitativeServcies, Virginia Assistive Technology System, University of Virginia, WoodrowWilson Rehabilitation Center.
Engstrom, B. (1993) Ergonomics: Wheelchairs and Positioning. Posturalis,Hasselby, Sweden.
Hoppenfeld, S. (1976) Physical Examination of the Spine and Extremities. Appeton-Century-Crofts, Norwalk, CT.
Huss, D. et al (1994) Recreating the Wheel: How s and Why s of Wheelchairs andSeating for Neurologically Impaired Adults. Conference sponsored by WoodrowWilson Rehabilitation Center, Department of Physical Therapy, Fishersville, VA.
Kapandji, A. (1974) The Physiology of the Joints, Vol. 3: The Trunk and VertebralColumn. Churchill Livingstone, New York, NY.
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Kreutz, D. (1998) Fundamentals in Assistive Technology, 2 nd Edition: Module VIII -Characteristics of Seating and Positioning Technologies. RESNA Press, Arlington,VA.
Maurer, L.E., and Vanhoy, M. (1998) AHCA Assistive Technology Services AssistiveTechnology Training Program Manual, Module 1: Seating and Mobility. AmbulatoryHealthCare Corporation of America, Fredericksburg, VA.
Maurer, L.E., and Vanhoy, M. (1998) UVA-HealthSouth Seating and Mobility TrainingCurriculum Manual. University of Virginia-HealthSouth Rehabilitation Hospital,Charlottesville, VA.
Medhat, M.A., and Hobson, D.A. (1992) Standardization of Terminology andDescriptive Methods for Specialized Seating: A Reference Manual. RESNA Press,Arlington, VA.
Minkel, J.L. (1996) Sitting Solutions: Principles of Wheelchair Positioning andMobility Devices. Conference sponsored by Therapeutic Service Systems, Baltimore,MD.
Nixon, V. (1985) Spinal Cord Injury: A Guide to Functional Outcomes in PhysicalTherapy Management. Aspen Publishers, Inc., Rockville, MD.
Schuch, J. and Sprigle, S. (1995) Wheelchair Seating and Positioning: ImprovingYour Services from Assessment Through Follow-Up. UVA Rehabilitation EngineeringWorkshop, University of Virginia , Charlottesville, VA.
Zollars, J.A. (1996) Special Seating: An Illustrated Guide. Otto Bock OrthopedicIndustry, Inc., Minneapolis, MN.
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_________________________________________________________________
RESOURCES _________________________________________________________________
Centers for Medicare and Medicaid ServicesMay 5, 2005 Decision Memorandumwww.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143
Clinical Criteria for MAE Coverage
www.cms.hhs.gov/CoverageGenInfo/Downloads/MAEAlgorithm.pdf
NORIDIAN Administrative Services, LLC (Medicare Administrative Contractor,Jurisdiction D)
Documentation Checklistswww.noridianmedicare.com/dme/coverage/
NAMES National Association of Medical Equipment Suppliers
625 Sister Ln., Suite 200Alexandria, VA 32314(703) 836-6263
An organization of suppliers of various types of medical equipment. TheirRe/habilitation Section has established Standards of Practice for RehabilitationTechnology Companies. They sponsor and participate in several trade shows.
NRRTS National Registry of Rehabilitation Technology Suppliers
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NRRTS National Registry of Rehabilitation Technology Suppliers3223 South Loop 289, Suite 600Lubbock, TX 79423(800) 976-7787
An organization composed of Rehabilitation Technology Suppliers, dedicated to theprovision of high quality rehabilitation technology services to people with disabilities.All NRRTS members meet specific professional membership requirements and agreeto adhere to the NRRTS Code of Ethics and Standards of Practice.
RESNA Rehabilitation Engineering and Assistive Technology Society ofNorth America
1700 N. Moore St., Suite 1540Arlington, VA 22209-1903(703) 524-6686http://www.resna.org/resna/reshome.htm
An interdisciplinary association of professionals, providers, and consumers withinterests in disability and assistive and rehabilitative technology. RESNA promotesresearch, development, education, advocacy, and provision of technology.
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_________________________________________________________________ APPENDICES
_________________________________________________________________ Providence Alaska Medical Center, Wheelchair and Seating Clinic Referral Form
Noridian Documentation Checklistswww.noridianmedicare.com/dme/coverage/docs/checklists/manual_wheelchairs.pdf
www.noridianmedicare.com/dme/coverage/docs/checklists/group_1_pwc_and_group
_2_pwc_no_power_options.pdf
www.noridianmedicare.com/dme/coverage/docs/checklists/group_2_single_power_option_group_2_multiple_power_option.pdf
www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_single_and_multiple_power_options.pdf
www.noridianmedicare.com/dme/coverage/docs/checklists/group_3_power_mobility _device_no_power_options.pdf
Documentation Requirements for K0823 Power Wheelchair Claims. Noridian, 2009.