The Goals of Wheelchair Prescription Maximize mobility and functional capacity Prevent morbidity Provide proper measurement and ensure safety Maintain physiological function Promote participation in ADLs (BADL, MRADL, and IADL)
ELEMENTS OF PRESCRIPTION Medical History Physical Capability Abilities/Impairment
Medicare Rules The In Home Rule: Patient must have difficulty mobilizing in their home to complete Mobility Related ADLs (MRADLs) Patient must be unable to perform MRADLs with cane, walker, or crutch in order to qualify for a wheelchair Community Mobility is not Medicare’s primary concern
Assuring Appropriate Fit In order to promote optimal seating and positioning a patient must be properly measured and fitted for a wheelchair
Types of Wheelchairs Medicare K CODES K0001 = Standard Wheelchair K0002 = Hemi Wheelchair K0003 = Lightweight Wheelchair K0004 = High strength Lightweight Wheelchair K0005 = Ultralightweight High strength Wheelchair
Types of Wheelchairs Medicare K CODES K0006 = Heavy Duty Wheelchair K0007 = Bariatric Wheelchair K0009 = Other Manual Wheelchair K0010 = Standard Weight Frame Motorized Wheelchair Medicare pays to rent for the first 10 months, then becomes purchase.
Light Weight and Ultra lightweight Chair Types Decreased weight Ease of adjustability Decrease in repetitive strain injuries with prolonged use Ability to lower seat-to-floor height Better hand contact with push rim Improved efficiency with propulsion.
SLING SEAT Pros Easy to fold Easy to clean Light Cons Promotes perspiration Promotes poor posture - posterior pelvic tilt, hip IR/Adduction
Solid Seat Base and Solid Seat Insert Pros Firm Promotes postural control Cons heavier harder to fold
Seat width - too narrow Difficulty with transfers Promotes skin pressure Danger of pressure ulcers on greater trochanters Uncomfortable
Seat width - too wide Promotes unequal weight distribution on ischial tuberosities Promotes shearing Promotes back and shoulder pain Leads to difficulty with self propulsion
Seat depth - too short Increases pressure on distal thigh Alters weight distribution Wheelchair may tip over
Seat Depth - too long Promotes sacral seating Promotes posterior pelvic tilt Promotes skin pressure in the popliteal fossa
Seat Height Consider mobility requirements and transfers Lower if utilizing lower extremities to propel Too low, there is increased pressure on buttocks Too high, difficulty with transfers, wheelchair may not fit under table.
Recline Overall length of wheelchair is longer a full recliner reclines to 180 degrees Difficult to propel - in its upright position it is 6” longer than a standard wheelchair May promote shearing during positional changes When reclined, does not enable end user with an adequate view of the environment
Tilt-in-space Entire seat and back tilt as single unit maintaining original angle. Minimal to no shear For effective pressure relief, tilt must be >45 degrees
Tilt-in-space: Advantages Alleviates shear Enhances postural control Decreases effects of gravity that may lead to spasticity Maintains seating position during weightshifts Has a tight turning radius
Tilt-in-space: Disadvantages No ROM benefits Difficult to self perform pressure relief Urine may run backwards from leg bag during tilt. Difficult to perform catheterization Items on UESS may slide off Increases height of wheelchair
Combining recline & tilt Useful for patients at risk for pressure ulcers, orthostasis, and hip flexion contractures Assists with achievement of weightshifts Enhances overall seating and positioning for patients with complicated seating and positioning requirements Adds weight, width and bulk.
Backrests Provides balance support Provides freedom of movement Higher backrest, provides more support, but contributes to less freedom of UE movement Lower backrest promotes freedom of movement, but offers less support If backrest is too low, it may contribute to decreased trunk stability
Armrests Maintain trunk balance and comfort during propulsion
Armrests-positioning Too High: poor posture, shoulder elevation and pain, will not fit under table. Too Low: poor posture, increased trunk flexion, may compromise respiration.
Wheels Mag - heavier with less shock absorption Spoke - lighter with better shock absorption, easier to propel but more maintenance
Tires Pneumatic with airless insert - rubber inner tube. FLAT FREE Pneumatic - air inner tube, light, smoothest ride, flats Solid rubber - durable, heavy, harsh ride on rough terrain, no flats, primarily indoor use
Camber Definition: The angle that the wheel makes with the vertical axis - between 2-12 degrees Advantages: increased stability, easier to propel at fast speeds and easier to turn. Disadvantages: increased width and increased wear and tear on tires.
Casters Small - tighter turns and greater curb clearance Large - smoother ride and better on rough terrain
Handrims Aluminum - good friction Friction-coated - for impaired hand function Projection knobs increase weight and width but enable self propulsion for patients with decreased grasp
Foot rests and Leg rests Swingaway detachable: most commonly prescribed. Elevating legrests: used as an aid for improving LE circulation and minimizing edema *when used with tilt One-piece footboard / foot box: with LE contractures or malformations Adjustable angle footplates to accommodate contractures
Foot rests and Leg rests Too high - increase pressure on ischial tuberosities Too low - feet will hit floor, drag on curbs, and sidewalks
Brakes (wheel locks) Toggle lock (most common) : push to lock or pull to lock. Scissor: on sports wheelchairs Extensions -standard on one-arm drive so patient can reach across and operate wheel lock on opposite side of wheelchair using only one hand
Cushions Foam - heavy, but provides positioning and pressure relief Gel – heavy, but provides pressure relief, stability and positioning Air (Roho) – provides pressure relief Requires Careful Maintenance! Is not for everyone! Custom Molded
Scooters Advantages Highly desired among patients Appear less disabled (as per patient report) Can be disassembled for transport in car Disadvantages Increased turning radius Tippy on rough terrain Does not fit in elevators or standard apartment setting
Power Wheelchair Requires letter of medical necessity (LMN) Requires a reliable motor output to operate the powered mobility vehicle Requires screening of cognitive, visual, and auditory skills
Power Wheelchair Advantages Promotes mobility for patients with complex conditions Can fit in elevators and standard apartment settings Can be customized to meet patients seating and positioning requirements Promotes participation in “in-home” BADLs and MRADLs
Goals of Prescription Maximize mobility and functional capacity Prevent morbidity Maintain physiological function Promote participation in ADLs (BADL, MRADL, and IADL)
Case Study P.A. P.A. is a 19 year old male with diagnosis of T6 paraplegia sustained postoperatively in the Dominican Republic during scoliosis surgery. Assessment ROM: BUEs WNLs AROM & PROM BLES Contractures at Hips and knees Tone: BUES Grossly Intact BLES Hypertonicity Trunk Mild Hypotonicity Strength: BUEs Good 4/5 BLEs – unable to fully assess due to spasticity Coordination: Grossly Intact Sensation: Grossly Intact Balance: Static Short Sitting Balance Fair + Dynamic Short Sitting Balance Fair
Case Study P.A. continued Vision / Hearing: Intact Skin Integrity: hx stage 3 pressure ulcer on sacral region, healed with darkened skin over region Cognition / Perception: Grossly Intact BADL: Independent (Self Catheterizes) Performs Push-up Transfer IADL: Independent MRADL: Performs all ADL from Wheelchair Accessibility: Lives in Accessible Apartment with Family Vocational Goal: Attend College Weight 125 Height 5’4” What type of wheelchair would you prescribe? What are key features for consideration? What type of seat cushion is indicated?
Case Study R.H. RH is a 74 year old divorced male with diagnosis of COPD, Emphysema, Chronic Systolic Heart Failure, and CAD with Ejection Failure of 25%, DM Type II Assessment ROM: BUEs WFL AROM & PROM BLEs WFL AROM & PROM Tone: Intact Trunk & Extremities Strength: Good 4/5 Trunk & Extremities Coordination: Intact Sensation: Impaired Light Touch on Bilateral Feet Balance: Static & Dynamic Short Sitting Balance Good Static & Dynamic Standing Balance Poor Vision & Hearing: Grossly Intact Skin Integrity: Intact Cognition / Perception: Grossly Intact
Case Study R.H. continued BADL: Modified Independence with Dressing, Bathing and light Meal Preparation using DME and Adaptive Devices Transfers with Supervision – Contact Guard IADL: Assistance from HHA 3 days 4 hours weekly (Laundry, Shopping, Household Maintenance, and Cooking) MRADL: Ambulates with Rollator Walker due to decreased endurance and increased fatigue, uses oxygen via nasal cannula History of falls while performing MRADL within the home Lives alone in private home with accessible entrance Travel: Ambulette Service Weight 200 lbs Height 5’11” Vocational Goals: Retired What type of wheelchair would you prescribe? What are key features for consideration? What type of seat cushion is indicated?
Case Study R.E. RE is a 69 year old female with diagnosis of CVA with Left Hemiplegia and COPD Assessment ROM: RUE & RLE WNL PROM & AROM LUE PROM moderately limited all joints LUE AROM No Volitional Movement LLE PROM WFL LLE AROM No Volitional Movement Tone: LUE Moderate Hypertonicity LLE Moderate Hypotonicity Trunk Mixed Abnormal Tone Strength: RUE & RLE Good 4/5 LUE: 0/5 LLE 0/5
Case Study R.E. continued Coordination: RUE Grossly Intact LUE Severely impaired Sensation: RUE, RLE, Trunk Intact LUE, LLE, Trunk Impaired Balance: Static Short Sitting Balance Fair Dynamic Short Sitting Poor Balance Poor Static Standing Balance Poor Dynamic Standing Poor Skin Integrity: Sacral Pressure Ulcer Stage 2, Left Ischial Pressure Ulcer Stage 2-3 Vision & Hearing Grossly Intact Cognition: Intact BADL: Moderate to Maximum Assist from Husband IADL: Maximum Assist from Husband and Daughter
Case Study R.E. continued MRADL: Non-Ambulatory, Performs all ADL in Manual Wheelchair, Dependent on Family for Mobility Indoors and Outdoors Sitting Position: Left Side Head, Neck, and Trunk Leaning with Trunk Rotation Lives with Husband in Accessible Apartment Building with Elevator Vocational Goal: Retired Since CVA Weight 160 lbs Height 5’3” What type of wheelchair would you prescribe? What are key features for consideration? What type of seat cushion is indicated?
References Biodynamics http://www.biodynamics.us/index.php, accessed 10/17/14 http://www.biodynamics.us/index.php Cooper, RA: Wheelchair selection and configuration, New York, 1998, Demos. Garstang, SV, Rand, R: Wheelchairs and power mobility. In PM&R Knowledge Now. http://me.aapmr.org/kn/http://me.aapmr.org/kn/, accessed 10/20/14
References Koontz, AM, et al: Wheelchairs and seating systems. In Braddom, RL, editor: Physical medicine and rehabilitation, ed. 4, 2011, Philadelphia. NHIC: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements http://www.medicarenhic.com/viewdoc.aspx?id=5 05http://www.medicarenhic.com/viewdoc.aspx?id=5 05, accessed 9/30/10
References RESNA: Rehabilitation Engineering and Assistive Technology Society of North America http://www.resna.org/http://www.resna.org/, accessed 10/1/14 Wilson, PE, Kishner, S: Seating evaluation and wheelchair prescription. In Medscape. http:emedicine.medscape.com/article/31809 2-overview