Neuro PT2- Topics Related to Wheelchair Evaluations

Who uses WCs?

1. Any age

2. Any diagnosis

3. Any environment

4. Any funding source

5. Any life-style, life-role or vocation

6. Ongoing/permanent need or temporary

Match patient characteristics/needs to customize WC

1. Fit

2. Skin protection

3. Postural support

4. Function

5. Environment

6. Transportation

7. Durability/maintenance

8. Affordability

How long can it take to get a custom WC?

Typically several weeks to months, depending on patient needs and manufacturer.

~3-6 months

How often does someone get a new WC?

5 years/or sooner if needs change significantly (i.e. new dx/change in fctn)

What is the HAAT Model

How assistive tech interacts with the individual and how it assists them

What are the parts of a WC

Standard WC height

18”x16”, 19.5” height

Hemi WC height

17.5’’ Floor to seat height

Super low WC height

Less than 17.5’’ Floor to seat height

Tall WC height

18” depth, seat height

Amputee WC axel placement

posterior axel to prevent falling fwd

Ultra light weight WC consideration

Weight, adjustable axel placement

Recliner WC considerations

Seat to back angle

Tilt-in-space WC considerations

Floor to seat angle

Power WC considerations

Power base vs. frame

Position of the drive wheel

K001 WC and use

Standard w/c

used for transport rather than seating

K002 WC and use

Standard hemi wheelchair

used for transport rather than seating

Different than standard due to height

K003 WC and use

Leightweight WC

Adjustability to meet the user’s seating/positioning needs

Access floor for propulsion

Adjust armrests for transfers

WC used >2hrs/day

K004 WC and use

High strength, light weight WC

Allows increased adjustability for long term users, weighs less

Access floor for propulsion

Adjust armrests for transfers

WC used >2hrs/day

K005 WC and use

Ultra lightweight WC (<30lbs)

Lightest and most configurable (no front rigging)

Adjustable rear axle

Individual’s primary mode of mobility and help with ADL participation

K006-7 WC and use

Heavy-duty & Extra heavy duty wheelchair

Match features with K1-3s, reinforced for people >300lbs

Vertical seat to floor height effects

Influences dump

What is dump

Front Seat-to-Floor Height (FSTH) - Rear Seat-to-Floor Height (RSTH)= Dump

Benefits of increasing dump

Tilting the seat back anchors your pelvis securely against the backrest via gravity.

Keeps you from sliding forward.

Vital if you have limited core strength or poor sitting balance.

Axle placement

Post=more stable

Ant=more tippy

Scooters

1. Steer with tiller

2. Wider turns

3. Longer length

4. Able to break down for transport (it weighs 135lbs so think about who’s transporting it)

Group 2 powered WCs

• ‘Consumer’

• Tilt, seat elevator, elevating leg rests

• Power recline not available

• Need eval by ATP

Group 3 powered WCs

• ‘Rehab’

• Specific diagnoses

• Expandable electronics

• Multiple functions

• Need eval by ATP

Front Wheel Drive

• Drive wheels in front

• Pulls wheelchair over obstacle

• Better traction

• Turning is behind user

Midwheel Drive

• Drive wheel in middle

• 2 sets of casters in front and back

• Get stuck on obstacles/uneven terrain

• Smaller turning radius

• Drive wheel under user

• Easier to drive

• Can pull closer to counters and tables

Rear Wheel Drive

• Drive wheel behind user

• Less common

• Very stable

• Large front casters can interfere with foot positioning

• Turing happens in front of user

Power seating functions

• Posterior Tilt

• Anterior Tilt

• Recline

• Elevating leg rests

• Seat elevator

• Standing

Posterior tilt function

• Pressure relief

• OH/posture event

• Rest breaks

• Changing for incontinent episodes

Anterior tilt function

• Transfers

• Reaching (30 degrees you need knee blocks)

Recline function

• Hamstring contracture prevention

• Bladder and spasticity management

Elevating leg rests function

• Swelling

• Spasticity

Seat elevator function

• Reaching

• Transfers

• Interactions

Standing function

• Bladder

• Cardiovascular

• Stretching

• Spasticity

Questions for matching a wheelchair with a person’s lifestyle or activity

• Where it’ll be used and the terrain

• Activities you do/want to get back to doing

• How will you transport the chair

• How much of the day will be spent in the chair

• How will you transfer

• If you need help, who will help and what features do they need

Physician responsibility for WCs

• Has the burden of proof for justifying the need for specialized manual and power wheelchairs

• Must provide a prescription for the wheelchair

• For Medicare to pay for a wheelchair, the physician must complete a face-to-face mobility evaluation Documentation must include five items

• Must complete a “seven element order”

Physician 5 items

• chief complaint

• physical assessment (height, weight, neuro fctn,

• cardiovascular)

• Medical conditions limiting mobility

• Impact on ADLs

• Why alternative devices are insufficient

PT/OT responsibilities for WCs

• Assessment

• What components are appropriate with ATP

• Complete trials

• Write LMN

Supplier (RTS)/Equipment Rep/Vendor/DME dealer responsibilities for WCs

• Can compare the characteristics of wheelchairs and parts, and durability.

• Equipment rep

  • Can provide trial equipment

  • Could be present during trial

  • Answer questions

  • Demonstrate use of equipment

Funding source responsibilities for WCs

Establishes guidelines and requirements for paying for equipment

Different payers have different input on the evaluation process

• Case managers

• OVR

• Home accessibility

Medicare funding source

For home

Used as model

Medicaid funding source

Community

Wheelchair Procurement Process

• Initial eval

• Vendor visit

• Paperwork

• Submission to insurance

• Determination

• Delivery

WC procurement- Physician

• Refers pt for eval

• Automatic as part of inpatient PT referral

WC procurement- Therapist

• Evals pt

• Automatic as part of inpatient PT referral

• WC clinic if in outpatient

WC procurement- supplier

• Measures, orders, contributes to eval

• LMN submitted to supplier

• Required by most payers for K005, group 2, or above powered WCs and other equipment

*LMN good for 6months for medicare

WC procurement- payer

• May require home visits for accessibility

• Reviews documentation for auth/denial

• 30 day turn around

Evaluation

• HPI/dx

• PLOF

• Home environment

• Current equipment

• Objective measures

• Trials

HPI

• Dx

• PMHx

• Falls

• Skin integrity

• Life roles/activities

• Daily routines and lifestyle (can they stand to shower/dress safely)

PLOF/home enviornment

• Home set up

• Entrance/accessibility

• Hours w/ caregivers

• Ability to complete MRADLs

• Adaptive equipment

• Transportation

Current equipment

• What

• How old

• Condition

• Hours being used

• Why it isnt meeting needs

• How to operate

• Ability to operate

Objective measures

• Pain rating 

• ROM

• MMT

• Handheld Dynamometry

• Edema

• Functional Mobility

• Tone/Spasticity

• Sensation

• Gait

• Motor function

• Posture and positioning

• Measurements

• Outcome measures

Motor function

• Determines how patient will operate WC

• Manual- mode of propulsion

• Power- controller type/alternate driving modes

Posture

Essential for max functionality

Ideal sitting position important for

1. Arousal/eye contact

2. Respiratory and gastrointestinal health

3. Minimizing musculoskeletal overuse injuries

4. Prevent acute and/worsening of chronic postural deformities

5. Maximize independence

6. Preserve skin integrity

Functional Seating- Stability

• UEs not needed for upright position

• Can use UEs for functional activities and participation

• Stable BOS (more so when COG behind)

• Persons with poor posture control achieve via kyphosis and sacral sitting

Functional Seating- Dynamic

• Movement in response to sensory feedback from NM system

• Planned movements

Ideal functional seating

• WB on ischial tubs, not sacrum

• Spine curved with slight kyphosis and lordosis (~5 degrees)

Skin integrity breakdown due to

1. Poor mobility

2. Poor sensation

3. Postural deformities

4. Previous skin issues

5. Age

6. Nutrition

7. Incontinence 

High risk areas in sitting

• Occiput

• Scapula

• Spinous processes

• Elbow

• Greater troch

• Sacrum

• Coccyx

• Ischial tuberosities

• Heels

Posture exam

• Observation (with and without support)

• Examine the pelvis in unsupported sittingIn all planes

• Examine the trunk in unsupported sittingIn all planes

• Examine the pelvis and lower extremities in supine

• Take anatomical measurements

Non reducible postures

posture that is rigid and unable to be corrected with a reasonable amount of force

• Wheelchair will be designed to accommodate the patient’s postural deformities. 

• Trying to correct a fixed posture can lead to skin breakdown

Reducible postures

• posture that is moveable and able to resume/partially resume a neutral position

• Wheelchair will be designed to reposition the patient into an optimally functional position to prevent worsening of the postural deformities/skin breakdown 

Pelvis movements in anatomical planes

Sagittal Plane: Tilt

Coronal Plane: Obliquity

Transverse Plane: Rotation

Pelvic tilt for WCs

ASIS/PSIS line is parallel to seat plane: neutral pelvic tilt

Neutral pelvic position risks and limitations

• Pressure distribution equal across ischial tuberosities and down femurs

• No increased areas of pressure

• Optimizes UE fctn

• Decrease LB strain

Posterior pelvic tilt risks and limitations

• Sacral and coccygeal breakdown

• Thoracic and spinous process breakdown

• Limited OH movement

• Shoulders at risk for pain and injury

• Limit ability to scan enviornment

• Collapse chest and limit excursion of breath

MOST COMMON

Anterior pelvic tilt risks and limitations

• Increased lumbar lordosis

• Increased contact of thoracic spine at backrest

• Decreased contact with lower backrest

• Increased pressure at anterior portion of the pelvis

• Impaired trunk control

• Tight hip flexors

• Increased risk of tipping wheelchair backwards

Pelvic obliquity assessment

• Assess Iliac crests

• Assess ischial tuberosities for depth of sitting position

Pelvic obliquity risks and limitations

• Ischial tuberosity breakdown

• Lateral trunk breakdown

• Can worsen or promote a scoliosis

• Limits shoulder range of motion

• Difficult to push a wheelchair straight

• Alters perception of environment

Pelvic rotation assessment

Locate ASIS b/l and assess which is most forward

• If R ASIS more forward, it’s a R rotation

Pelvic rotation risks and limitations

• Ischial tuberosity breakdown

• Decreases unilateral femur support

• Places shoulders at risk for injury and pain when pushing a wheelchair

Pelvic rotation causes

• muscle imbalances such as hemiplegia or decreased range of motion

• other premorbid issues, such as fractures and joint replacements

Pelvic rotation effects

Can cause rotations of the spine, trunk deformities, and back pain

• If reducible, correct with seatbelt or seating

• If non reducible, acomodate with backrest to meet pelvic angle

Trunk movements in anatomical planes

Sagittal Plane: Kyphosis/lordosis

Coronal Plane: Scoliosis

Transverse Plane: Rotation

Trunk position for WC

Heavily affects a patient’s ability to use their upper extremities for ADLs, propulsion/drive power wheelchair

Determines backrest type

• Reducible: trunk alignment

• Nonreducible: determine most functional position while preventing further postural deformities, skin breakdown

Trunk sagittal plane ideal position

• The tragus of the ear should be in line with the acromion process of the scapula 

• Thoracic spine kyphosis 

• Lumbar spine lordosis 

Trunk sagittal plane deviations

• Forward head posture 

• Increased or decreased thoracic kyphotic curve 

• Increased or decreased lumbar lordotic curve 

Trunk coronal plane ideal position

Seated symmetrically unsupported at edge of mat and able to maintain midline position 

Trunk coronal plane deviations causes

Structural/functional scoliotic or C-curves

Muscular tightness/spasticity

Trunk muscular weakness

*asses where lat support needed!

Trunk coronal plane curves

Trunk transverse plane ideal position

Cervical, thoracic, and lumbar vertebrae are aligned in neutral position

Trunk transverse plane deviations causes

• Cervical, thoracic, lumbar segment rotation 

• Muscular tightness/weakness 

• Spasticity 

Transverse plane pelvic rotation

Left anterior trunk rotation

True hip flexion

• determines seat to back angle via PROM of hip in supine before ASIS/PSIS moves

• used to prevent sliding in chair and skin breakdown

Windswept hips

named the way the knees are going

Knee Extension with True Hip Flexion 

Determines angle of leg rest hanger

Measured to point of hamstring tension

Tight hamstrings and large footrest angle

• Feet pull backward off leg rests

• Slide anterior causing sacral sitting

• Feet in danger of becoming entangled in front riggings of the chair

*less tucked someone is=larger turning radius due to longer chair

Ankle DF angle

Determines appropriate angle of leg rest footplate or justify angle adjustable footplate

Measurements in the coronal plane

• Hip width

• Chest width

• Shoulder width

• Width at widest part of body

*add 1-2” at hips

Measurements in Sagittal Plane 

• Seat to top of the head 

• Seat to axilla/inferior angle of the scapula 

• Seat to shoulder 

• Seat to elbow 

• Chest depth 

• Back to popliteal 

• Popliteal to heel 

Seat to top of head

• Note fwd head

• Selection of back and headrest

Seat to shoulder

Back and cushion selection

Seat to axilla/inf angle of scap

• Determines back height (PSIS to AC joint)

• Chair conversion dependent on functional level

• If propelling keep scaps free for ROM

• Power WC/tilt in space has back above scaps

Seat to elbow

• symmetry

• armrest type

• cushion selection

Chest depth

• use of chest positioning devices

• Lat position