CEUil

WheelchairSeating andi\/lobiiity

EvaluationBy Ginger Walls, PT, MS, NCS, ATP, andLauren Rosen, PT

An Introduction

T he history of the modem wheelchair came soon after one

of man's earliest inventions—-the wheel. Historians trace

wheeled mobility specifically designed for the sick or dis-

abled as fer back as 500 BCE. And advancements in the design

and technology of wheeled mobility have never stopped. The

design of the modern wheelchair originated late 19* and early 20^^

Centuries^—first with the inventions of self-propulsion push rims

and later with wire spoked wheels.

In the last two decades, technological advances have affected

every aspect of modern life. Wheelchair seating and mobility are

no exceptions. The advent of new designs, new materials, assistive

technology, and other associated equipment arc enabling users

with greater independence in addition to improved safety, com-

fort, and access.

With the availability of the latest technology, physical therapists

(PTs) must understand and integrate the various technologies in

seating and wheeled mobility with the individual patient and cli-

ent. This CEU article is an introduaory review of a seating and

2 8 « | a n u a r v 2 0 0 8

wheeled mobility evaluation. Physical therapists involved in this

area of practice need to be vigilant about maintaining competency,

which combines all the factors of physical therapist examination

and evaluation skills with knowledge of the current technology

and equipment and the skill to integrate both for an optimal out-

come for the patient/client.

Wheelchair ExaminationA wheelchair evaluation begins with a thorough examination

which includes an interview for patient/client history, systems

review, and specific tests and measures as indicated by the diagno-

sis, prognosis, and goals of the client.

PMH/Current Medical StatusJust as with any other physiail therapy evaluation, the first piece

of information obtained should be the clients past aJid current

history including chief complaint(s) and any medical diagnosis.

Ih i s gives the dierapist information about the client and should

be used to shape the remainder of the examination and evaluation.

Included with a discussion of the client's diagnosis should be all

current and previous medical problems including any issues that

Objectives

Upon completion of pan one of this continuing education (CE) article, you should be able to:

Describe the steps involved in a mat evaluation.

Perform a functional assessment in relation to the patient's

ability to operate a wheelchair.

Develop a plan of care for a padent using a wheelchair.

Understand wheelchair seating systems.

Identify the benefits ;md possible drawbacks of manual

wheelchairs, power mobility devices, and power wheel-

chairs.

Describe the interrelationship of the physical therapist

with suppliers, manufacturer representatives, and pay-

ers/case manitgers in facilitating the successful provision of

recommended equipment to (he client.

Understand the Clinical Criteria Algorithm for

Wheelchair Prescribing.

CEU InformationOn successiul completion of the examination, .1 CEU (=2 contact hours) and a certificate of completion will be awarded.

The fee is $28 for APTA members, $49 for nonmembers (fee subject to change). This and other CE offerings from APTA can

be accessed online. (Go to www.apta.org. Select "Professional Development" under "Aieas of Interest." Then select "Continuing

Education," then "Online Courses.") APTA has been approved as an authorized provider of continuing education by the

International Association for Continuing Education and Training (Provider #380) and is recognized by the Board of Certification

Inc to offer continuing education for Certified Athletic Trainers (Approved Provider #P1151).

may affert seating. Additionally, any past or pending surgeries

should be listed.

Careful consideration should be given to anticipated or

potential changes in the person's finiction or psychosocial role

changes. For instance, when working with an individual with a

progressive disease process such as a multiple sclerosis (MS) or

amyotrophic lateral sderois (ALS), the wheelchair must meet

current and potential needs as the diseases progresses. Likewise, a

child or adolescent certainly may have growth or other anthropo-

morphic changes. This shotild be taken into consideration when

ordering a new chair or related equipment.

It is important to know which medications a client currently

takes. Certain medications can affect the clients cognitive ability.

This can interfere with manual wheelchair propulsion or power

wheelchair operation.

The physical therapist should ascertain the clients level of

bowel and bladder control. Certain types of aishions are better for

use with clients who fi-equently are incontinent. Using the wrong

tjpe of cushion for individuals who are incontinent can cause

many problems. A pungent odor may occur with certain cushions

due to a tendency to retain the odor from a draining wound,

incontinence, or from the person's body odor.

The status of a clients vision and hearing are important if

wheelchair propulsion is an option. This applies to both manual

and power wheelchairs because it can affect the client's ability to

successfully move around both indoors and outdoors.

Finally, establish the client's cognitive level and ability to com-

municate. Cognition is especially important when a power wheel-

chair is being considered. Clients need a sense of catise and effea

to safely operate a power wheelchair.

SkinDuring the examination, the physical therapist should ques-

tion a client about any past skin issues. Once a client has had a

decubitus ulcer, his or her skin is at best 80% the strength that it

was prior to the ulcer.' This means that the client always will be

more susceptible to fiarther skin issues. When designing a seating

system, it is important to know what has previously been used or

tried that worked or didnt work and the genesis of the pressure

ulcer, so the appropriate protection will be designed in the new

system.

Ask the client or caregiver about pressure relief The physical

therapist needs to record the method and frequency of achieving

pressure relief This is important when choosing an appropriate

29

CEUilwheelchair and when designing a newseating system because, without this infor-mation, the therapist titiknowingly mayremove a part of the wheelchair that theclient or caregiver was using to achievepressure relief.

Current Wheelchair/ DMEEquipment

Proper documentation of the client'scurrent equipment is necessary. The ageof the wheelchair and all positioningequipment should be noted as well asthe wheelchair's serial number. Manypayer sources require the wheelchair orseating system to be a certain numberof years old before they will replace thechair or part.

Following the basic description ofthe wheelchair and the parts, include acomprehensive list of the problems withthe current chair. Documenting disrepairhelps in the decision as to whether torepair or replacement the equipment.Clients should be asked what they like/dislike about their current equipment.Also, document any significant changein client status since acquisition of thecurrent equipment. This information canto help to justify the need for a new sys-tem. Without any issues with the currentwheelchair, most payer sources will notfimd a new wheelchair or seating system.

Posture in CurrentWheelchair

Assess the client's posture and position-ing in the wheelchair, the size of the sys-

tem in comparison to his/her size, and anyparts of the chair that could cause injury.

Sitting ToleranceThe length of time that the client tises

the chair during the day is important tonote. How often does he/she transfer inand out of the chair? How does he/shetransfer (use of sliding board, caregiversupport, etc)? How long does he/she sitat one time and what are the limitationsto sitting (eg, pain, pressure relief)? Themethod for transferring and the amount ofassistance should be documented.

Functional StatusA client's function^ status is very impor-

tant. Administering a questioimaii-e like theFunctioning Everyday in a Wheelchair toolcan provide a good base level of function.-Additionally, when administered a fewweeks after a new piece of equipment isprovided, this measure functions well as apost delivery outcome measure. Additionalconsiderations include:• Can the client ambulate indepen-

dently? If so, for what distanceand with what assistive devices andorthotics? Can the person ambulatesafely and perform mobility-relatedADLs in a safe and timely manner? Isthere a history or risk for falls? If so,how frequently? Can he/she ambulateefRciendy?

• For clients who can propel a wheel-chair, the distance and method ofpropulsion should be noted. Does theclient use both hands to propel, or justone? Can the client propel on unevensurfaces?

• For clients who use a scooter or apower wheelchair, can they access thecontrols and operate it safely?

• How a client transfers is an area ofassessment. Document the method fortransferring and the amount of assis-tance required.

• Document the assistance a clientneeds for performing activities of dailyliving. Is the client a caregiver? Do

the clients participate in food prepara-tion? Can they eat independently?Do they need assistance while eating,or do they have a G-tube? What typeof assistance do they need with bath-ing, toileting, and dressing? Do theyparticipate in cleaning of the home ordoing laundry? Are they responsiblefor shopping for the home?

• Does the client attend work or school?If so, where and for how many hoursa day? Are there requirements for workor school? When outside of the houseat work or school, does the clientrequire assistance?

Living EnvironmentA LliciiLs living environment can be

important for determining his or herwheelchair needs. With whom does theclient live? Is there 24-hour supervision? Inwhat type of home does he/she live? Arethete steps to enter? Is the home accessibleindoors? What is the width of doorwaysand hallways?

A home assessment may be necessaryto determine whether the type of wheel-chair recommended will be successful inthe client's environment. Tliis also willalert the family or caregivers of any homemodifications need to be made prior to theprescription of the appropriate wheelchair.

When determining an appropriatewheelchair, consider the type of vehicle theclient uses for transportation. Does he/sheride a bus? Is there a tie-down system in thevehicle? If the client uses bus transporta-tion to/from school there may be require-ments for positioning equipment on thewheelchair.

SystemsThe s)'stcms review is a brief examina-

tion of the 4 primary systems (musculosk-eletal, neuromuscular, integumentary, andcardiovascular/pulmonary), in addition toscreening(s) based on information gainedduring the history review. The systemsreview also should document findingsrelated to communication, affect, cogni-

Wheelchair Seating^""Mobility Evaiuation

tion, learning style, etc. Any concerns that

are not within the scope of the evaltiating

physical therapist shold be referred to the

appropriate provider.

Mat EvaluationOnce the background information is

obtained from the interview, it is time to

perform the mat examination. This exami-

nation should take place outside the clients

wheelchair and on a mat table.

SpasticitySpListicit)' can positively or negatively

affect a client's seated posture. Some clients'

spasticity gives them the trunk support

CO sit upright. For others, it causes their

bodies to straighten at times and cause the

clients to fall from the wheelchair it they

are not positioned properly. Many indi-

viduals with cerebral palsy have adductor

spasticity that restilts in the hips remain-

ing significandy adducted. Continuously

positioning the hips can contribute to hip

dislocation so it should be addressed in the

seating system. Other patients may have

windswept hip deformity due to a hip

dislocation. Additionally, if their spasticity

results in any signifiaint posturing, note

[his as well as it will affea their positioning

in the wheelchair.

The most common method of evaluat-

ing spasticity is the Modified Ashworth

Scale^. This has been shown to be a reliable

and repeatable assessment.

SkinDocument the clients current skin

condition. If the client has any pressure

points or ulcers, the location, size, and

severity of the redness or wound should

be noted. This is especially important with

payer sources that only pay for certain

types of cushions if the client has current

skin issues.

If a client is cognitively intaa and can

answer questions, then sensation should be

assessed. Note whether the client has insen-

sate areas. This allows for proper design of

the system to assure the least risk of any

injiuy or any development of skin Issues

on the insensate area.

SupinePelvis

Is diere any pelvic obliquity? If so,

which side is lower or higher, and by how

much? Is the obliquity fixed or flexible? If

flexible, to what extent? How much can

be corrected? How much force is required?

Can the client tolerate this correction, both

positional and for skin integrity?

What is the resting pelvic position? Is

the pelvis positioned in neutral, anterior,

or posterior tilt? Can this positioned be

changed or is it fixed?

Is the clients pelvis rotated? If so,

which side is forward? Is the rotation fixed

or fiexible?

SpineIs the client's spine straight? If not, does

he/she have scoliosis, kyphosis, or lordosis?

With scoliosis, make sure to note whether

tiie apex is on the left or the right and

where the apex is located; cervical thoracic,

lumbar, or sacral. With kyphosis or lordo-

sis, note the location and the severity of

the deformity. With ail deformities, note

whether they are fixed or flexible.

Clients with spina bifida usually have

a gibbus on their back. Note the location

and the severity of the gibbus and the skin

condition on the gibbus.

Rib CageThe rib cage should be even. If one side

is higher or one side is rotated forward of

the other side, it should be examined. Also

note whether there is a posterior rub hump

in clients with scoliosis and whether the

deformity is fixed or flexible.

Lower ExtremityRange of Motion

The best position to initially measure

lower extremity range of motion is supine.

In this position, the trunk and upper

extremities are stable and can relax so it

is easy to maniptJate the lower extremi-

ties. Goniometers should be used when

possible to get specific range of motion

information.

The first joints to be exmined are the

hips. For wheelchair seating and position-

ing, evaluate hip flexion and hip abduc-

tion/adduction. These are common areas

of tightness and can limit the proper

positioning of the client. It also should be

noted whether the client has any type of

windswept or frog leg deformities. How

much hip flexion is available prior to

posterior pelvic tilt? This angle will help

determine the seat to back angle of the

wheelchair.

The next joint is the knee. Establish

both the general passive knee flexion/

extension and the hamstring length. The

most popular method of assessing ham-

string tighmess is by using the popliteal

angle. For wheelchair seating this should

be done with the hip flexed to maximum

flexion prior to posterior pelvic tilt, then

extend the knee and measure this angle.

Tight hamstrings can significantly limit

wheelchair positioning because it can cause

a posterior pelvic tilt if the client seat to

back angle is not open enough or the angle

of the leg rests does not accommodate

the hamstring tightness. Additionally, tight

hamstrings can affect the angle of the leg

rest hangers.

The final joints in the lower extremity

are the ankles. Ankle equinus occurs fre-

quently in individuals who do not ambu-

late and can limit the ability of the client to

keep his/her feet on the footrests and will

affect the position of the rest of the body

if not accommodated. Additionally, inver-

sion is very common. This prevents the

feet fiom sitting flat on a footplate that is

positioned in neutral; therefore, an adjust-

able angle foot plate or even a padded foot

box may be indicated if significant impair-

ments are found.

These motions may need to be re-evalu-

ated in a sitting position to assess the effects

of a seated posture on the motion as it is

continued on page 33

PTm a g a ? i ti 1

CEU'Icontinued from poge 31

tombined. (The hamstrings tighmess may

appear different in sitting because the cli-

ent sits with a posterior pelvic tilt.)

Upper ExtremityRange of Motion

L'ppcr extremity motion typically

does not limit wheelchair positioning.

However, it can affect proptilsion or the

ability to use a joystick. Additionally, if the

client has significant contractures, it may

cause difficulty with positioning devices

such as armrests and lap trays. A general

assessment including shoulder mobility,

elbow flexion/extension, and wrist and

hand motion should be included in the

examination. If there are limitations, then

specific goniometric measurements can

be taken.

SittingIn sitting, the same evaluation of the

pelvis, spine, and rib cage should be com-

pleted as was done in supine. Frequently

clients do not have limitadons in supine

but have them in sitting.

StrengthStrength of both the upper and lower

extremides can be assessed in a seated posi-

tion. An upper extremity strength assess-

ment should include shoulders flexion/

extension, elbow flexion/extension, wrist

flex ion/extension, and grip strength. In the

lower extremities hip flex, knee flex/exten-

sion, and ankle dorsiflexion/plantarflexion

shotild be assessed.

Shoulders/Spinal AlignmentThe shoulders should be examined to

determine if they are level. Note if one

side is higher than the other. Additionally,

if there are any signs of shoulder sublux-

ation, this should be assessed and included

in the evaluation. Reassess the spinal align-

ment in sitting. What position facilitates

upright alignment? How much force is

required to correct their posture and to

what posidon can they tolerate this cor-

rection? Where do these forces need to be

on the person?

MeasurementsMeasurements should be taken with

the client sitting in the optimal position

so that the wheelchair will fit properly.

This can take two people: one to hold the

client and the other to measure. Taking

these measurements with the equipment

vendor may be helpful. Custom wheel-

chairs are built to the measurements of

the client. It the therapist incorrectly takes

the measurements and the chair does not

fit the client, then there will be prob-

lems with the fit of the new wheelchair.

Working as a team with the company

that orders the chair les.sens the risk of the

chair being sized improperly.

Pressure MappingSome clients may require pressure

mapping as part of the evaluation process

to determine the most appropriate wheel-

chair cushion or back. Pressure mapping

shows the inter&ce pressure between a

client and a seating surface. This technol-

ogy provides a visual image of the entire

contact area showing the pressure distri-

bution and peak pressures. This relative

comparison between surfaces can help

determine whether a cushion or a back is

properly matched to a client.

This technology is not required for all

patients. Clients who may benefit fi"om

pressure mapping are those widi significant

wound histories, absent sensadon, clients

who have pelvic obliquities, those with

significant protruding bony prominences,

those who cannot communicate their dis-

comfort, to determine the most effective

means of pressure relief {eg, tilt vs recHne

vs tilt and recline) and for objective assess-

ment regarding the pressure distribution

of a seating system. A client with a level

pelvis, no history of decubitus ulcers, or

good sensation usually does not require

this evaluation.

Using this technology requires a good

understanding of the equipment so it can

Wheelchair Seating^""'Mobility Evaiuation

be applied properly. If the instrumentation

is used improperly or the equipment is

set up incorrecdy, then wrong choices can

be made. Considering that presstire map-

ping can be time consuming, it should be

reserved only for those who require it and

only performed by individuals with the

requisite knowledge.

Functional AssessmentWhen interviewed, a client may over- or

underestimate his or her ability to perform

some mobility skills. Consequently, the

physical therapist should view and evaluate

these skills as appropriate.

Sitting Balance/Head ControlSitting balance helps to determine the

amount of positioning eqiiipment neces-

sary to keep the client seated properly. The

evaluation should include whether a client

can maintain unsupported sitting and if

so, for how long. Tests like the Functional

Reach Assessment also can be used."*

Once trunk control is determined, head

control should be assessed. If the client has

no trunk control or limited trunk control,

head control should be assessed with the

trunk properly supported to get the best

idea of the clients fijncdon.

Standing BalanceIf appropriate, standing balance should

be assessed. There are several measures

including the Berg Balance Scale and the

Tinetti Gait and Balance scale that can be

used to document standing balance.^- ^

Gait/AmbulationIf the client can ambtilate, what is his

or her gait pattern? How far can he or she

walk, and with what assistive devices? Is he

or she able to walk safely and in a timely

manner? Tests like the Timed-Up-And-Go

can be used as appropriate.^

Most payer sources have rules about

whether they will pay for wheelchairs for

clients who are fUII-time ambulators. By

documenting the quality, safety, and efH-

PTin a g a / i n e • 33

CEUdency of ambuladon, and the client'sability to complete his/her mobility andmobility related activides of daily living(MRADLs), a client who is a fiilltimeambulator may qualify for a wheelchairthat he or she would not qualify for basedon ambulation status alone.

Wheelchair Propulsianbur cliciui who c;in propel a wheel-

chair, the distance and method of propiJ-sion should be noted. Does the client useboth hands to propel or just one? Does hefoot propel the wheelchair? Can the clientpropel on uneven surfeces? Does propul-sion cause the client any pain or shormessof breath?

Vistial observation and videotaping canbe used to evaltiate the kinemadcs and thepropulsion pattern for the client. Somefacilities have a SmartWheel. This deviceallows PTs to gather informadon aboutthe Idnedcs of the clients propulsion.

This information assists in wheelchairand positioning selecdon, determiningthe correct wheelchair set up, and it can beused to help prevent some upper extrem-ity repeddve stress injudes.^

Shoulder injudes are a common riskfactor for individuals using a wheelchairfor mobility. During wheelchair propul-sion, the shoulder moves through anarc of motion against resistance. Evenpropulsion at a low intensity of wheel-ing, with the contact forces within theshoulder{s) low, the muscle forces in therotator ctiff are high and could causeinjury, especially due to the repetitivenature of proptilsion.

Shoulder pain has been studied pri-marily in patients' status post spinal cordinjury (SCI). Researchers have associatedshoulder pain and the resultant dysfunc-tion in the SCI population with overuserelated to weight bearing. More than two-thirds of SCI manual wheelchair asersreport experiencing or having experiencedshoulder pain. The frequency and durationof the attacks increase with the dme sincethe onsdet of the disability. Prevelence

and intensity also is signiflcantly higherin subjects with tetraplegia and in subjectswith paraplegia.

TransfersHow a client transfers is an importajit

area of assessment. If the client transfersindependendy, is the technique safe? Isthere an increased risk of upper extremityinjury or impact injury by performing dietransfer? Can he oniy transfer to certainlevels of heights?

Once all of these areas are assessed, thephysical therapist can begin co work widithe client and the supplier to determinethe most appropriate equipment and set-up to maximize Rincdon.

Evaluation to Plan ofCare: ''Putting All thePieces Together"

The next step is to take the subjec-tive and objective clinical informationobtained in the history, systems review,and evaluadon and develop equipmentrecommendations to assist the client inmaximizing his or her independence andsafety with MRADLs.

"The clinical domain encompasses allissues about the user, including the diag-nosis and prognosis, the impairments andthe funaional limitations, the measure-ments, the environment of tise, and otherunique client charactedsdcs. The TechnicalDomain encompasses available productsand information about product perfor-mance tliat charaaetize its qualities andperformance that are significant to die userin making a selection. The clinical assess-ment in Seating and Mobility Evaiuationis a process of bringing together these twodomains to synthesize a match betweenthe user specifications and product per-formance. An output of the cliniail assess-ment is a prescdption and jusdfication diatsummarizes the skillful synthesis of theclinical and technical domains restating ina product specification."^

The clinician must be aware of his or herlevel of pracdce within these domains andmay need to seek out resources, includingmore experienced clinicians, manufacturerrepresentatives, or suppliers, for assistancein one of the two domains or in how tosynthesize diese two domains. A clinicaldecision and radonale is necessary for everyselection and recommendation concerninga clients wheelchair ajid seating system-from the type of wheelchair base to theselecdon of every piece of equipment onthe wheelchair and seating system.

Plan of CareGoals

The plan of care is determined throughthe development of goals in considerationof die client's unmet seating and mobil-ity needs, arising in the course of typicalMRADLs. The goals are centered on theprinciple that the recommended device(s)will bddge the gap between die clientsimpairments and Rinctional mobility leveland seating and funcdonal mobility needs.The input of the client and caregiverregarding goals, needs, and expectationsis cdtical in determining appropriate goalsand achieving opdmal outcomes.

Wliile clients often need changes intheir seadng and wheelchair systems overdme, these changes can be extremely chal-lenging for clients to adapt. In addition,while it is important to present clients withchoices and new informadon about equip-ment that is available to them, seating andwheelchair systems that have proved towork well for clients over the years oftenare the best guidelines for determinadon otthe next seadng system and/or wheelchair.

Interventian:Selecting the Device(s)

Functional classificadon of the clientsseadng and mobility needs assist in deter-mining features of technologies that meettheir identified needs based on the assess-ment information and the client's goals.'*^

An example of a funcdonal decision

3 4 « | a n u a r y 2 0 0 8

clinical Criteria for Mobility AssistiveEquipment (MAE) Coverage

JTmaeuzin i - • 35

CEUilmaking tree is found in the ClinicalCriteria Algorithm for WheelchairPrescribing. The decision tree in thisalgodthm allows the clinician to movethrough a progression from the leastcosdy and least intrusive mobility assis-tive equipment (MAE), ruling them outif appropriate, until the mobility devicewith the required features is reached."

Most clients rely on a third partypayer to ftind the equipment recom-mended for them. "A cdtical point isreached, where the aspirations of the userand the professional jtidgment of the cli-nician intersea with funding constraints,probably of the third party payer. Thereis often a disdna difference between aclinically prescribed optimum solutionand a fundabie one. A rational compro-mise may be able to be secured if researchevidence can be presented to support thecase being made."'-

Clinicians must have an understandingof third party ftinding cdteria for differenttypes and classes of MAE in order to assistthem in providing fundabie eqtiipmentrecommendations, as well as in under-standing how to jtistify any recommenda-tions, utilizing evidence where possible,in ftincdonal langu^e meaningful to thestakeholders involved.

Understanding funding constraintsalso assists the clinician in working withthe supplier and in educating the cli-ent on their options. Both the supplierand the manufacturer representadve canbe excellent resources regarding technicalaspects of the equipment recommended,as well as insurance reimbursement andregulations.

Working with the supplier and manu-facturer, clinicians often can assist clientsin making choices regarding features ofequipment that might not be fundedby the client's insurance but might beof significant benefit to the client, eitherby facilitating greater independence withfuncdonal mobility (ie, a seat elevatorto allow level transfers) or by preventingimpairment (ie, a dtanium ultra light-

weight wheelchair to help prevent repeti-tive stress injuries).

Seating SystemsSeating systems include the clients

wheelchair seat cushion and back, as wellas any other positioning devices/accesso-ries integral to maintaining opdmal clientpositioning for ftincdon in the wheelchair.Seating systems can var)' from very simpleto very complex.

Cushions are made out of various typesof matedal that determine their useflilnessin positioning and/or skin protection. Gel,fltiid, foam, air flotadon, thermoplastichoneycomb, powered, and various com-binations of these matedals are used inmanufacturing different types of cushions.Cushions generally can be contoured, pla-nar, or custom contoured. Each type ofcushion is designed to meet the fimctionaland impairment needs/goals of differ-ent types of client. They all have vary-ing degrees of immersion, stability, shearforces, shock absorption, and temperaturesensidvity, as well as heat and moisturemanagement. The maintenance required,ease of modification, and weight will varydepending on the design.

Gel and fluid cushions offer someimmersion and can be good for pressuredistdbudon with minimal maintenance,yet are heavier and may be uncomfortablefor clients with sensation.

Foam cushions generally are lightweight and comfortable and offer goodpositioning, but may cause shear andhave limited immersion depending on theshape, density, firmness, and modulus ofthe foam. They generally have a shorterlifespan than other cushions.

Air cushions are lightweight and offerexcellent pressure distribution, but canrequire a higher level of maintenance andcompliance fot clients, or may not offersufficient support for clients with balanceimpairments.

Cushions using combinations of thesemedia attempt to match the desirablequalities of each medium and ofi et the

disadvantages. As mentioned in the evalu-adon section, tdal of various cushions,as well as pressure mapping, is integralto the selecdon of the opdmal cushion,pardcularly for clients with a history ofskin breakdown.''

Custom contoured cushions offerexcellent pressure relief and positioningfor clients whose postural needs cannotbe met by any "off the shelf' product.These clients may have significant spasdc-iry, scoliosis, pelvic obliquity, leg lengthdiscrepancy, or other Impairments thatmake a custom contoured cushion nec-essarj'. Disadvantages of a custom con-toured seadng system are that it may hedifficult to assess before ordering, transfersmay be difficult due to the contour ofthe system, or the client may have higherpeak pressure on bony prominences if notposidoned properly in the seating system.These systems are more labor intensiveand expensive than "off the shelf ' prod-ucts, but are appropdate for clients withsignificant postural support and skin pro-tection needs.

Cushions are assigned according toCMS coverage criteda to 7 different cat-egories: genera] use cushion, skin pro-tection cushion, adjustable skin protec-tion cushion, positioning seat cushion,skin protecdon and positioning cushion,adjustable skin protection and posidoningcushion, and custom febricated ctishion.According to CMS criteda, clients qu;i]ifyfor these various types of cushions basedon their lCD-9 code, history of skinbreakdown, sensation, ability to performeffecdve pressure reliefs, and posturalneeds. Wheelchair backs fall into variouscategodes, similar to cushions.''* Thevarious mantifactures offer informationon which of dieir cushions tall into eachcategory to assist clinicians in the selec-don and jusdfication process.

Like cushions, wheelchair backs usevarious types of matedal. Vadous backsoffer different degrees of postural sup-port, adjustability of height and angle,lateral support, and lumbar support.

3 6 » | a i i u n r y

Some backs are extremely lightweight.

Others are not. TTie mounting hardware

that attaches the back to the back posts of

a wheelchair somedmes allows the back co

be easily adjusted or removed to fold the

wheelchair, and somedmes it does not.

These are important considerations, in

addition to the postural needs of the client,

in the selection of the back.

Other wheelchair seadng accessories

integral to the seating ;md positioning of

the client in the wheelchair include: lateral

thoracic supports, headrests, pelvic belts,

abductor/medial thigh supports, adductor

wedges/lateral thigh supports, lateral hip

gtiides, foot boxes, antedor chest stipports,

shoulder retractors, residual limb supports,

trays, shoe holders, ankle/toe straps, arm

troughs, and hand supports. All accessories

must be selected to meet the individual

needs of the client and must integrate with

die recommended seating and mobility

S)'stem. The goal should be to provide the

minimal iimount of support necessary to

achieve the desired positioning and allow

dytiamic fimctional skills.

Manual WheelchairsManuiil wheelcliaiis are grouped into

several classificadons in accordance with

CMS K-Codes. The depot (KOOOl) wheel-

chair weighs 35 or more pounds, has no

adjustability, is designed for temporary use,

and often is used as a hospital or airport

fleet wheelchair.

The high strength light weight

(K0004) wheelchair usually weighs 30-35

pounds and has some adjustable features.

The K0004 wheelchair is the CMS clas-

sification used for rental wheelchairs. It

is indicated for mantial wheelchair users

who have long term need to perform

Wheelchair Seating^"''Mobility Evaluation

wheelchair based MRADLs in an accom-

modated environment; who c;in self-pro-

pel using their arms or legs ot a combina-

tion of them; and who require minimal

adjtistments in the seadng configuradon

to optimize wheelchair propulsion or

seated posture.

Key features of the K0004 wheelchair

include the availability of an adjustable

back height, up to 19" tall and the abilit)'

to have the seat-to-floor height, measured

from the seat rail to the floor, set at

standard (19.5"), hemi (17.5"), or super

hemi (15.5") heights, or somewhere in

between, to assist in accommodating foot

propulsion, transfer ability, environment

access, and taller or shorter client heights.

The adjustable back height is required

to accommodate for the height of the

cushion required for proper postunil sup-

port of users of this wheelchair and to

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APTACONSULTING SERVICE

Your Link to the Expertise You Need to Succeed

FT ni a g a /. i n ' 37

allow clearance of the shoulder girdle forpropulsion.'^' "

The ultra lightweight wheelchair(K0005) typically weighs less than 30pounds iind has greater adjustability thanthe K0004 wheelchair. Some titaniumultra lightweight wheelchairs may weighcloser to 20 pounds. In addition, theK0005 wheelchair is available with twotypes of frames: rigid and folding.

Rigid frames offer lighter weight andhigher durability and performance thanfolding frame wheelchairs.

Folding trame wheelchairs offer greaterease of storage and transport for manywheelchair users.

The key adjustable feature of theK0005 wheelchair is the adjustable axleplate. Indications for the adjustable axleplate include the ability to change therear seat-to-floor (STF) height relativeto the front STF height to assist withposture, balance, and positioning in thewheelchair due to decreased trunk control.The adjustable axle plate also allows dierear wheel axle to be adjtisted anteriorly(to make the wheelchair easier to roil andmore maneuverable) or posterior (to makethe wheelchair more stable).

The combination of rear STF and ante-rior-posterior adjustabilit)' also allow thewheelchair to be set up for optimal push-rim biomechanics, which is critical for cli-ents with decreased upper extremity func-tion to allow independence with mobilityand to prevent upper extremit)' repetitive

stress injury by facilitating increased accessto the push rim. The optimal push rimangle is to position the rear axle so thatwhen the hand is at the 12:00 positionon the push rim, the angle at the elbow isbetween 100 and 120 degrees.' '

The K0009 wheelchair is an addi-tional classification of manual wheelchair.It includes some titanium majiual wheel-chairs, as well as the adult manual tilt-inspace wheelchair. Some titanium manualwheelchairs have a K0005 classificationwhile others have a K0009 classifica-tion for individual consideration accord-ing to CMS. Titanium wheelchairs offerlighter weight and more flexible frameswhich both aid in maximizing indepen-dence, dampening vibration, and reduc-ing repetitive stress injuries and increasewheelchair durability. '

Adult mantial tilt in space wheelchairswith or without manual recline often areused with clients who have extensive posi-tioning needs and frequently are depen-dent in wheelchair propulsion and pressurereliefs. Common populations who mightuse this type of wheelchair include peoplewith CP/MR, traumatic brain injury, andadvanced Alzheimer's disease.

Power MobilityDevices (PMDs)Power Operated Vehicle orScooter (POVs)

A I'OV (power operated vehicle orscooter) may be indicated for a clientwho needs assistance with mobility, cannotpropel a manuiil wheelchair, but does notneed the positioning assistance offered bya power wheelchair. Clients using POVsmust be able and willing to operate thePOV and be able to transfer safely in andout of the POV. POV users generallyappreciate its non-medical appearance, buthave to put up with its many disadvan-tages including the following: decreasedmaneuverability, decreased seating andpositioning options, decreased stability,decreased upper extremity biomechanical

positioning when operating the tiller, anddecreased safety in transfers due to hav-ing to negotiate the platform of the POVwhen transferring.

Many POV users want to use thePOV to assist with community mobil-ity. However, many of these users also arecovered by Medicare, which does not covercommunity mobility. The therapist mustdetermine if the device is needed and canbe used to allow independence tor in homemobility if the client is a Medicare recipientand K-Iedicare is to be used to pay for thePOV. A client certainly may pay tor a POVout of his or her own pocket if this is hisor her choice.'^'

Pov/er WheelchairsThe power wheelchair offers signifi-

cant advantages over POVs in position-ing, maneuverability, stability, UE bio-mechanics, transfers, and the abilit)' tostipport more than one additional powerseating option.

One way to differentiate among powerwheelchairs is by the location of the drivewheel—that is, the wheels that the motorspower to move the wheelchair. Powerwheelchairs come in rear wheel drive(RWD), front wheel drive (FWD), andmid wheel drive (MWD) or center wheeldrive (CWD).

FWD power wheelchairs offer bettertraction and torque for hill/ramp climbing,but offen "fish tail" going down hill or athigher speeds and may be difficult to oper-ate for someone not used to FWD due tothe back end of the wheelchair bumpingthings when turning.

MWD and CWD power wheelchairshave the drive wheel directly under thebase of support, offering a smaller mrningraditis. Many MWD power wheelchairsalso offer all 6 wheels on the ground withsuspension systems built onto the frameof the wheelchair to ;illow independentarticulation of the right and left sides ofthe wheelchair frame over uneven stirfeces.RWD power wheelchairs are the moretraditional power wheelchair design, have a

Wheelchair Seating^''''Mbilit Evaluation

wider turning raditis, but are able to oper-

ate most smoothly at the highest speeds.

Power wheelchairs are available with

two types of electrotiics: programmable

;uid non-programmable.

Non-programmable electronics gen-

erally have one drive mode that is set

at factory pre-programmed speeds which

may be able to be adjusted with a speed

potentiometer.

Programmable electronics ustially have

4 or 5 programmable drive options, are able

to run the power seating systems throtigh

one ot the drives if needed, and also may

be able to interface with alternative drive

systems, such as sip'n'puff, head controls,

chin controls, or other proportional or

non-proportional systems. Programmable

electronic power wheelchairs also may be

able to interface via infrared capabilities

to a client's environmental control or aug-

mentative communication device(s).

Like manual wheelchairs, power

wheelchairs are rated for different weight

capacities. Bariatric options are available

in both manual and power wheelchairs.

The weight capacity of 250 pounds is

generally considered the end of stan-

dard weight capacity, and the beginning

of the need for heavy duty and up to

bariatric weight capacity. Some power

wheelchairs also are designed to support

power seating systems.

Power seating systems offer tilt, recline,

seat elevation, power standing, and lateral

tilt. Indications for these systems include

pressure relief, endurance, bladder man^e-

ment, positioning for transfers, or other

MRADLs performed in the wheelchair.

Power seating systems can be operated

through the joystick or with a separate

button or switch.

Power tilt provides clients with the abil-

ity to perform weight shitt without loss

of positioning in the wheelchair. Power

tilt also may assist with management of

inclines, improved respiration and diges-

tion, positioning of the trunk, edema man-

agement, and can inhibit spasticitj'/reflexes

by changing body position against gravity.

Power recline sometimes can cause

sheering of the skin on the back or loss of

positioning when returning to the sitting

posidon in the wheelchair. This can be

particularly true with clients with a custom

molded seating system. Clients with spinal

cord injury may require power recline to

change position to assist with bladder emp-

tying. Power recline distributes pressure

over the largest surtace area, may allevi-

ate orthostatic hypotension, allows supine

transfers, and can assist in accommodation

ofl^phosis.

The use of power tilt and recline in

combination offers the best pressure relief

for clients for whom this is a concern.

Both dlt and recline can assist with pro-

viding mtiltiple funcdonal positions for

MRADLs and witli decreasing fodgue,

managing edema, bowel and bladder func-

tions, and respiratory impairments.

Lateral tilt offers an alternative method

to provide pressure relief, provide posi-

doning, improve digestion, assist with

transfers, and assist with upper extrem-

ity function for clients with decreased

shoulder deltoid strength. Power seat ele-

vation assists with transfers by making

level or downhill transfers possible within

the clients environment and assists with

performance of MRADLs and general

upper extremity function where reaching is

involved. A power wheelchair with a power

stiuiding feature allows clients to perform

MRADLs, as well as vocadonal or other

funcdonal tasks, at a standing level. In

addidon to assisdng with funcdon, power

standing also offers physiologic benefits,

including pressure relief, improved bone

density, improved circuladon and vital

organ capacity.' *' **

CMS classifies power wheelchairs into

Croups 1, 2, 3, 4, and 5. Croups 1 and

2 provide the least amoimt of program-

mability and additional seadng func-

tions. Croups 3 and 4 provide the most

programmabilit)' and additional seating

functions. Pediatric power wheelchairs

are in Croup 5. The various manufac-

tures offer information on which of their

power wheelchairs fall into each category

to assist clinicians in the selection and

jusdfication process.''*

Other powered mobility options include

push rim activated power assist devices and

power add on systems that allow a manual

wheelchair to be converted to a joystick

driven power wheelchair also are available.

Indications for these devices might include

upper extremity weakness or impairment

sufficient to limit fiill dme propulsion,

and to retain the portability of a mantial

wheelchair for transport.

Justification"In everyday practice, the clinicians jtis-

dficadon letter highlights the specification

in terms that resonate widi die policies and

traditions of the funding agency. A chal-

lenge for the clinician is to know where to

draw the line between those specifications

on which they are willing to yield and

those that compromise their professional

responsibilities to their client."^

A letter of medical necessity (LMN)

must be written by the clinician, not the

supplier. A good LMN includes all of

the pertinent information described above

in the interview and evaluation sections.

Specifically, the following elements are

essential:

• A descdption of the clients primary

and secondary di^noses, impairments,

funcdonal limitations and MRADL

limitations, height and weight charac-

terisdcs, home/work/school environ-

ments and caregiver sittiadon.

• A descdpdon of current eqtiipment,

including serial number, equipment

age, size and what is/is not working

well and whether it can or cannot

be repaired or modified to meet the

client's current needs, and how the

clients needs may have changed since

obtaining the current equipment.

• A descripdon of why the equipment

specified as a result of the evaluadon

process is cridcal to the independence,

safety and mobility, and MRADL

performance of the client, including

PTm a ga 2 i n e • 39

prevention of secondary complications

of skin breakdovm, upper extremity

repeddve stress injuries, and scoliosis.

Utilization of research references to

support recommendadons may be

used in the letter of medical necessity

or made available by the clinician for

appeal if needed.

From RecommendationTo Delivery

Working cioseiy with suppliers, manu-

fecturer representadves, and payers/case

managers can facilitate the successful pro-

vision of recommended equipment to the

client. The supplier ultimately is respon-

sible for ordering equipment from the

mantifacturer and secudng funding fi-om

the third party payer. The supplier receives,

assembles, and prepares the equipment for

delivery. The supplier is also the endty on

whom the client must rely for equipment

repairs and assistance with maintenance.

Follo^-up TreatmentPlan

At the dme of evaluation, the clinician

determines the plan for fitdng, training,

and delivery of the equipment. Depending

on the needs of the client

and the complexity of the

equipment, the clinician

may work with the supplier to decide on

the best course of follow up for each indi-

vidual client. The more complex the client

needs and the equipment, the more likely

that one or more return visits to physical

therapy may be necessary to ensure proper

fit, adjustment, and tise of all the equip-

ment ordered.

For example, if a specific seat-to-back

angle was indicated due to a lack of hip

fiexor range of modon, the clinician must

ensure proper wheelchair set up to accom-

modate/allow fit of the client in the wheel-

chair. Or if a wheelchair with an adjust-

able axle plate was ordered, the clients

wheelchair must be set up with desired

rear STF and anterior/postedor position

of the rear wheel axle to ensure both safety

and optimal push rim biomechanics for

propulsion.

During fitting and follow up visits, cli-

nicians must educate clients on the proper

use and care of the equipment. In addidon,

clients may benefit from return to therapy

for educadon and training in any of the

following acdvides with their new equip-

ment: transfers, posture, pressure reliefs,

proptilsion/mobility techniques, commu-

nity mobility training (ie, negotiation of

curbs, ramps, uneven terrain), commu-

nity resources, safety, MRADLs using their

equipment, and transportadon. Proper

propulsion technique is significant to the

prevendon of repedtive stress injury, as

well as energy conservation and fimctional

mobility independence. The semiciictilat

propulsion pattern, dudng which the users

hand drops below the push rim during the

recovery phase using long smooth strokes,

assists in better biomechanics and greaterstroke efficiency.'^'21 (^

DeterminationOf Outcomes

"Following deliver)' and training with

the device, a determination of outcomes or

the ability of the device to meet the goals

established at the time of assess-

ment is made. This can be done during

the training sessions, through a follow up

questionnaire, phone consultation, or a re-

evaluation visit."'^

References1 Sarvis C. (I9'J9). Wound nianagemenr in ihe elderly. CME

Resource. 37-56.2 Mills T, Holm M, Treller E, Sehmdcr M. Fingerald S. &

Biiningcr M, (2002). Development and consumer vaiidaiionof the funaional evaluation in a whedcliair (FKW) instru-ment. Disnbility andRehabiliMtion. lA (\l2li) i%Ab.

3 Bohannan W & Smidi M. 11987). Inferrater leli.ibility ofa modified Ashworih stale of muscle spasticiiy. PhysicalThempy, 67: 206-207.

4 Duncan P. Weiner D. Chandier ], Studenski S. (1990).Functional reach: a new clinical measure of balance, journalofGtromologf. 45: 192-195.

5 Berg K. Wciod-Dauphnee S. Williams JI, Cayion D:Measuring balance in the elderly. Preliminary developmentof an instrument, Physiothempy Qmndi, 41: 304-311. 1989

6 Tincrti MK (1986), Performance-orienrcd assessment ofmobility problems in the elderly patients. Journal of theAmerican Gerianies Society, 34, 119-126

7 I'odsiadio D & Richardson S. (1951). The timed "Up &Go"; a test of basic funaional mobility for frail dderly ^ -v)Ti. Journal of the American Ctrianic Society, 39; 142-148.

8 Consortium for Spinal Cord Medicine, (2005), Preservationof Upper Limb Function Following Spinal Cord Injury:A Clinical Practice Cluideline for Healthcare Profeisionais,Paralyzed Veterans of America.

9 Fer^son-Pell M. et al. (2005). The Role tif WhcdchaitSeating Standards in Determining Clinical Praaices andF u n d i n g Policy, Aisislive Technology Jgurnal, 1 7 ( 1 ) ,

ID i'araly/ed Veterans ol America Clinical Practice Guidelinesfor the Preservation of Upper Umb Funaion Folliwing SCI,www, pva.org

11 Ml.N Matters No MM379!. Centers for Medicareand Medicaid Services, Avaikblt at www.cms.hhs.gov/MLNMattcts/\rticlei/downloads/MM3791.pdf AccessedDecember 6, 2007,

12 Ferguson-Pell. M, et al. (2005). The Role of WheelchairSeating Standards in Determining Clinical Practices andVaaAm^'i'oMcy. AssisiitY Technology Jourfml. 17(1).

13 PVA CPG for Pressure Ukcr Prevention and Trearment fbl-Iciwing SCI

14 Federal Renter.

15 Coalition to Modernize Medicare Coverage Policy forMobility Produns (CMMCMP) Qinician Task Force.Available at www.cliniciantasktotccurg

17 HERL References to Support Wheelchair Prescription..Available at www, hcrlpitt.otg/references,htm

18 RESNA Position Paper on the Application iif Seat-Elevating[5c\-ices for Wheelchair Users; Rehabilitutioii Engineeringand Assistive lechnology Society of North America,September 20O5. Available at w\vw,fesna,oig,

19 RESNA Position Paper on the Application of WheelchairStanding Devices; Rchabilitatiiin Engineering and AssistiveTechnology Society of North America, Available at www.re.sna,org,

20 Paralyzed Veterans of America Clinical Practice Guidelinesfor Pressure Ulcer Prevendon and Trearment Following SCI.Available at www.pva.otg

21 Bonninger ML, SoLoa AL. Cooper RA, Fitzgerald SG,Kiiontz AM. and Fay BT Propulsion patterns and push rimhiomechanics in manual wheelchair propulsion. Archives ofPhysical Medicine ami RekMilation 83 (2002): 718 -23,

^Examination

Exam QuestionsTo answer the following questions for .2 CEU (2 contact hours) you will need toread the article Introduction to Wheelchair Seating and Mobility Evaluation on thepreceding pages. Please choose the one best answer for each question. After com-pleting your examinatian, use the mail in answer form on page ^ or go to www.apta.org and choose "Professional Development/' then "Continuing EducationCourses," then "Online Courses," then "CE Series: Continuing Education Series"to fill out the online Examination form and pay for this CEU course. Please alsocomplete the brief online "Evaluotion Form for Online Courses,"

1. Factors that help determine equipment recommendationsfor a client include all of the following except:

a . insurance/financial constraintsb. client goals and expectations

c. client impairment and functionol leveld . television advertisements for mobility devices

2. Seating systems may consist of all of the following itemsexcept:

a . Seat cushion

b. Seat backc. Wheeled mobility bosed . Lateral thoracic supports

3. Reasons for recommending an air flotation cushion for aclient include all of the following except:

a . Lightweightb. Pressure distribution

c. Excellent for positioning clients with bolance ortransfer prablems

d. History or good performance for client over time

4 . The distinguishing feature of tha K0005 ultra lightweightwheelchair is

a. The adjustable axle plateb. The height adjustable back

c. Variety of colors available for the framed . The variety of armrest types available

5. For a client with impaired upper extremity strength whowants to continue to self-propel, oil of the following clini-cal interventions may assist in the prevention of repetitivestress injury except:

a . Adjustment of the axle plate anterior or posterior tofacilitate optimal push rim biomechanics

b. Adjustment af the axle plate up or down to facilitateoptimal push rim biomechanics

c. Utilizing spoke, instead of mag, wheelsd . Instruction in proper propulsion techniques

6. Which of the following seating systems may be most thera-peutic for a client with severe spastic tetraplegia due tocerebral palsy, scoliosis with pelvic obliquity, rotation, anda history of skin breakdown over boney prominences inthe spine?

a. Sling upholstery seat and back,

b. Custom molded seat and back systemc. Air cushion and back

d . Foam cushion and back

7. Advantages of a power wheelchair over a POV include allof the following except:

a . Increased maneuverability and stability

b. More advanced electronicsc. More available options for seating systemsd . Ability to transport in the trunk of a car

P T n i a g a z i n e

CEUilWheelchair Seating and Mobility Exam, continued from page 39

8. Characteristics of a good letter of medical necessity includeall of the following except:

a . Relevant clinical findings from the evaluation, includ-ing diagnosis, prognosis, functional status, heightand weight

b. Problems with the client's current equipment, includ-ing why it is no longer meeting his or her needs

c. Clinical rationale for the recommendation of the newequipment and why it will provide maximal clientindependence and safety and prevent secondarycomplications

d. A through C above and can be written by the sup-

plier.

9 . Power standing wheelchairs offor ail of the followingadvantages to the end-user except:

a . Easy to get funded by 3rd party payers

b. Good pressure reliefc. Improved functional position for MRADLs and voca-

tional activities

d . Improved bone density and circulation

10. Reasons to schedule a return visit(s) to PT when the client'snew wheelchair and seating system is delivered include allaf the following except:

a . To ensure proper fit and adjustment of all the equip-ment ordered,

b. To educate clients on the proper use and care of theequipment they have received.

c. To instruct the client in wheelchair mobility techniquesto maximize independence and safety with homeand community mobility.

d . To make it easier for the supplier.

Circle the correctanswer below.

1. a

2. a

3. o

4. a

5. a

6. a

7. a

8. a

9. a

10. a

c d e

c d e

b c

b c

d e

b c d e

b c d e

Name

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