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University of Colorado Denver Department of Physical Medicine and Rehabilitation

Assistive Technology Partners 601 E.18th Avenue Suite 130 Denver, Colorado 80203

Phone: (303) 3151280 Fax: (303) 8371208 TTY: (303) 8378964

Toll Free: (800) 2553477

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Wheelchair Seating and Mobility Evaluation Report Letter of Justification for Manual Wheelchair

Patient Name: Kate Date of Birth: Date of Evaluation: 2009 Therapist: Kelly Waugh, PT, MAPT, ATP

Medical Diagnosis: Spastic Quadriplegic Cerebral Palsy

Background Information: Kate is a 58 year old woman with spastic quadriplegic cerebral palsy who lives in a wheelchair accessible home with her elderly father and a full time caregiver. Kate has severe scoliosis, multiple joint contractures and deformities; however she is very healthy and well cared for. She is nonverbal but communicates with facial expressions. She does not utilize any assistive technology other than her wheelchairs.

Primary Problem and Reason for Referral: Kate is unable to tolerate upright sitting in her power wheelchair and Aspen Seating Orthosis for longer than 1 hr each day. She spends most of her time in a reclined, nearly supine position in a 25 year old recliner power wheelchair which she is unable to operate. Her body is supported with pillows. Kate was referred for an evaluation for a new wheelchair and seating system.

Current wheelchair and/or mobility equipment: Invacare Torque SP power wheelchair with Aspen Seating Orthosis (ASO); 6 years old Invacare Arrow recliner power wheelchair, 25+ years old Manual recliner wheelchair, 25+ years old

Problems with current wheelchair: o Current wheelchair seating system no longer fits due to increased deformity and joint

contractures, and consequently Kate is unable to tolerate sitting upright for more than 1 houro Her older wheelchair does not support her in a sitting position at all, but rather an inclined supine

positiono Manual wheelchair has no supportive seating and is used only when being transported in van

Functional Status

Activities of Daily Living (ADL) Status: Dependent for all personal care and activities of daily living. Eats by mouth

Transfer status: Dependent one person total lift

Ambulation: Unable

Manual wheelchair mobility: Unable to propel a manual wheelchair due to spasticity and incoordination of arms from cerebral palsy



Power Scooter Mobility: N/A

Power Wheelchair Mobility: Kate does not have adequate motor or cognitive ability to drive a power wheelchair

Cognition/Judgment: Significant cognitive impairment

Physical Assessment

Muscle Strength/Endurance/Tone/Motor Control: Kate has minimal active range of motion due to severe joint contractures in most all of her joints in the upper and lower extremities. She displays increased muscle tone and spasticity throughout her body. Kate has good head control and can turn her head to both sides. She can “kick” her legs somewhat, and can bring her arms towards midline but cannot reach midline.

Sitting balance/trunk strength: Kate is unable to sit unsupported

Seated Posture in wheelchair: Kate sits with significant asymmetry secondary to severe joint deformity. She sits with right convex scoliosis, and severe right pelvic obliquity such that her left iliac crest is tucked up under her ribs on left side. Her pelvis is rotated to the right relative to the wheelchair and to her upper spine. Legs are windswept to the left. Kate’s upper extremities are postured in elbow and wrist flexion, and shoulder extension/external rotation. She tends to keep her head rotated to the left, however she can actively turn to the right.

Range of Motion/Deformities: o Kate has a severe fixed Ccurve rotoscoliosis with convexity on right, with right pelvic

obliquity, such that her iliac crest is under her ribs on the left side. If her left hip is allowed to be in less flexion, there is some flexibility in her spine to allow pelvis to come down a bit on the left.

o Kate has multiple joint contractures, most notably very limited hip flexion on the left (50 degrees), and a fixed windswept deformity of hips to the left of 40 degrees with probable hip dislocation bilaterally. Attempts to flex her left hip past 50 degrees pushes her iliac crest up under her ribs, collapsing the concavity on the left, and compromising skin integrity in this area.

Sensation: Unable to test due to cognitive impairment, however appears intact.

Skin Integrity/Ability to Reposition: Kate is unable to reposition her body in any way, however she has good skin integrity and has no history of pressure sores. This is due to her excellent personal care and hygiene, and the fact that she lies mostly in supine and is repositioned by caregiver frequently with pillows. Her caregiver reports that there are “problem” spots that they watch carefully. Those include the concavity on the left side of her trunk, her right iliac crest, and right greater trochanter and femoral head. Kate is very thin and due to deformity has many bony prominences which place her at risk of pressure sores. Her risk of skin breakdown will increase as she spends more time in an upright sitting position.

Client’s Goals for manual wheelchair: 1. Optimize sitting posture/alignment in wheelchair within comfort in order to help prevent

further progression of spinal deformity 2. Increase sitting tolerance time from 1 hour/day to 8 hours/day 3. Minimize pressure over at risk bony prominences for prevention of sitting acquired decubitus

ulcers



4. Improve functional control of head/arms in sitting position to encourage activation of switches with right hand

5. Safe, dependent mobility in the home and in her rural community

Summary of Equipment Recommendations:

Many equipment options were considered during the evaluation with Kate, her father and her primary caregiver Rose. Our assessment of her seating and mobility needs determined that the following listed equipment is the most reasonable and cost effective alternative in meeting her needs:

Recommended Equipment Justification PDG Fuse T50 manual tilt in space wheelchair o 24” composite rear wheels o 8x1.5” casters o 19w x 15d o 90 degree swing away legrests

Kate’s current power wheelchair and seating system is 6 years old and no longer appropriate, safe or functional. The seating does not fit at all due to progression of deformity, and it places her at risk of skin breakdown – she cannot tolerate sitting in it for longer than 1 hour.

Her power wheelchair has old electronics and parts will soon be no longer available for repairs

Since Kate cannot drive a power wheelchair on her own, it is more appropriate for her to have a tilt in space manual wheelchair which is easier for her caregivers to maneuver in their home, and to easier to maintain.

A tilt in space feature is required in order to provide pressure relief as Kate cannot shift her weight and is at risk of skin breakdown due to her severe joint contractures and spinal deformity.

Flat free tires These are required in order to prevent a flat tire which is probable in the rural environment in which she lives.

Angle adjustable footplates Required to be able to mount the footbox at the proper angle

Footbox with custom padding Required in order to support her feet in their non standard asymmetrical placement which is due to her fixed windswept deformity of her hips.

Single post height adjustable armrests Required as Kate will sit in her wheelchair greater than 2 hours/day and needs arm supports at a specific placement which is asymmetrical due to scoliosis

OBSSCustom Contoured Seat cushion Kate requires a skin protection and positioning seat cushion due to inability to shift weight (complete



paralysis) and severe postural asymmetry (fixed pelvic obliquity and scoliosis); however a standard cushion cannot meet her needs because: She has a severe fixed right pelvic obliquity and right convex scoliosis, as well as significant hip contractures and deformity which cannot be accommodated in an off the shelf seat cushion

OBSSCustom Contoured Back support cushion Kate requires a positioning backrest due to significant postural asymmetry; however a positioning back support cannot meet her needs because: She has a severe fixed right pelvic obliquity and fixed right convex rotoscoliosis, which cannot be accommodated in an off the shelf backrest cushion

Whitmeyer Plush 1214” contoured head support o Removable adjustable hardware o Mounted offset to the left

Head support required to support her head when tilted

Padded pelvic belt Required to stabilize pelvis due to poor trunk and pelvic control and spasticity

IMPLEMENTATION PLAN: 1. The specifications of this prescription will be submitted to Kate’s primary care physician and

insurance carrier for authorization. Upon approval, the recommended equipment will be provided by Rocky Mountain Medical, and the fittings and delivery will be completed by Alan Barker of RMM in conjunction with this therapist.

2. Following funding authorization, Kate will be seen for 24 visits: a custom mold shape capture, a trial fitting of the custom seat cushions, an initial fit/delivery and possibly a post delivery follow up. These visits will take place at ATP with this therapist and Alan Barker of RMM. These sessions are required for wheelchair fittings and adjustments and training to ensure appropriate fit and safe functioning.

Report By:

____________________________ ________________ Kelly G. Waugh, PT, MAPT, ATP Date signed

I have read the above evaluation and agree with the recommendations stated therein. I follow this patient for medical care.

_________________________ _____________________ Physician signature Date signed

Cc:

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