The Promise of Assistive Technology to Enhance Activity and Work Participation (2017) / Chapter Skim
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3 Wheeled and Seated Mobility Devices
3 Wheeled and Seated Mobility Devices
Pages 35-98
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From page 35... ...
OVERVIEW OF THE USE OF WHEELED AND SEATED MOBILITY DEVICES The Survey of Income and Program Participation (SIPP) , conducted by the U.S.
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. The figure suggests a quadrupling of the estimated number of wheelchair users into the next decade.
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The most appropriate primary powered wheelchairs are customizable and have programmable controls (Paralyzed Veterans of America Constorium for Spinal Cord Medicine, 2005)
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POVs are three- to four-wheeled mobility devices that are manually steered and provide control for speed/braking. They serve as a supplemental form of mobility for those who can stand and ambulate to some degree.
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. Power Assist Wheelchair: Hybrid device that has some of the attributes of man ual wheelchairs and some of the benefits of powered wheelchairs.
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Describing all the different varieties, styles, and options of manual wheelchairs is not feasible; therefore, only broad groupings based on Medicare coding are included here. It is worth noting that outside of the United States, most countries use a coding scheme based on International Organization for Standardization (ISO)
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Wheelchairs coded K0006 are for individuals who weigh more than 250 pounds, while those coded K0007 are intended for individuals who weigh more than 300 pounds. Large individuals tend to be better served by powered wheelchairs because of the strain on their upper extremities that results from their propelling a manual wheelchair.
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. They provide limited support for seating balance and positioning; they require gross motor function of the upper extremities; and their fixed seating does not extend range of reaching, lifting, and carrying.
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However, they provide limited support for seating balance and positioning; they require gross motor function of the upper extremities; and their fixed seating does not extend range of reaching, lifting, and carrying. These chairs also provide minimal obility, which m severely limits participation in ADLs, community integration, and employment.
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From page 44... ...
These wheelchairs provide functional mobility with minimal limitations for participation in ADLs, community integration, and employment. Powered Wheeled and Seated Mobility Devices Although there are many different types of powered WSMDs, they fall into three broad categories: (1)
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From page 45... ...
Food and Drug Administration or covered by Medicare and other insurance companies. Examples include the Segway and similar products that are used as mobility devices without modification of their original equipment manufacturer design, as well as versions that have been radically modified (see Figure 3-7)
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, also known as s cooters, are three- or four-wheeled mobility devices that are manually steered and provide control for speed/braking. According to Medicare guidelines, to be eligible for coverage of a POV, a person must meet the general criteria described previously and also meet the following criteria: • The person must be able to transfer safely to and from a POV.
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From page 47... ...
These wheelchairs provide limited support for seating balance and positioning; they require gross motor function of the upper extremities; and their fixed seating does not extend range of reaching, lifting, and carrying. These chairs also provide minimal mobility, which severely limits participation in ADLs, community integration, and employment.
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From page 48... ...
used to turn the wheelchair. Group 1 powered wheelchairs are used by individuals whose needs are not adequately met by a manual wheelchair or a POV but who do not require a powered wheelchair from Group 3 or 4.
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Rehabilitation seating is used to help prevent pressure ulcers and/or to accommodate postural asymmetries and for individuals with impaired sensation. Group 2 powered wheelchairs are intended primarily for indoor use within home environments, but they are suitable for use over short distances outside of the home in ADA-compliant environments.
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Group 3 powered wheelchairs are suitable for indoor use and for outdoor use in ADA-compliant environments. Their durability is about 5 years with regular maintenance, with the frequency of maintenance increasing with the usage of power seat functions and alternative controls.
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A B FIGURE 3-13 Examples of powered wheelchairs in Medicare Group 4.
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Power Assist Wheelchairs Power assist wheelchairs (see Figure 3-14) are hybrid devices that have some of the attributes of manual wheelchairs and some of the benefits of powered wheelchairs.
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THE USE OF WHEELED AND SEATED MOBILITY DEVICES The committee used three data sources to examine WSMD use, including the association among diagnosis, impairment, and type of device used by working-age adults: (1)
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Level of Device Single category for Separate categories Healthcare Common Detail manual or electric for manual Procedure Coding wheelchair or electric wheelchair, electric System for Durable scooter wheelchair, and Medical Equipment -- scooter wheelchairs (manual and powered) and scooters Definition of Participants stated Must have been, or Diagnosis and Wheelchair Users that they used a must be expected to approved provider wheelchair at the be, using the device prescription for time of the survey for 12 months or medical necessity longer using CMS codes Date (years)
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From page 55... ...
As shown earlier in Table 3-1, the NHIS-D has separate categories for manual wheelchairs, electric wheelchairs, and scooters; the CMS DME files contain categories for manual wheelchairs, powered wheelchairs, and scooters. However, the SIPP contains a single category that includes manual wheelchairs, electric wheelchairs, and electric scooters.
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. Table 3-2 includes demographic information for a 5 percent random sample of beneficiaries from the Medicare DME files.
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-wheelchair 206 1.1 18,233 96.0 Power operated vehicle, Group 1 standard, patient weight capacity up 150 0.8 18,383 96.8 to and including 300 pounds continued
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Medicare beneficiaries aged 20–67. aData not shown for HCPCS wheelchairs with cell sizes <20.
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as powered. Table 3-4 shows a breakdown of the use of manual versus powered wheelchairs among the 5 percent DME sample by age and race/ethnicity.
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The first six primary diagnostic categories in Table 3-5 account for almost 79 percent of all users of WSMDs included in the Medicare DME sample. CLINICAL CONSIDERATIONS Factors Affecting Wheeled and Seated Mobility Device Selection The types of WSMDs that are most appropriate for particular individuals and the extent of their use depend on a number of factors, including body function and activity and environmental and personal factors (Cooper et al., 2015; Dicianno et al., 2011; Paralyzed Veterans of American Consortium for Spinal Cord Medicine, 2005)
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Medicare beneficiaries aged 20–67. ICD-9 = International Classification of Diseases, Ninth Revision.
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Individuals who are at risk of pressure ulcers (such as those with spinal cord injury, spina bifida, or vascular compromise) must be capable of independently performing pressure relieves.
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When powered wheelchairs are malfunctioning, moreover, they are generally unusable, so that a back-up manual or powered wheelchair is needed. A scooter may be appropriate for individuals who have some ambulatory ability but require a WSMD in their home, school, or work environment or in the community and are unable to use a manual wheelchair because of endurance limitations.
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Because of aging and overuse of their upper extremities, individuals who utilize primarily a manual wheelchair may need to add a power assist option to that wheelchair or progress to a powered wheelchair. Individuals with disorders characterized by progressive deterioration in their motor control, muscle strength, or endurance may need to progress sequentially from manual to power assist to powered wheelchairs, and those whose course is rapidly progressive may benefit from using a power assist or powered wheelchair earlier on.
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From page 65... ...
These evaluations need to be performed periodically depending on the severity and specifics of the cognitive deficits and the potential for cognitive deterioration. Factors Associated with Use of Wheeled and Seated Mobility Devices Even when an individual is appropriately matched to a WSMD, there are multiple factors that affect activity and participation.
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. Transportation of wheelchairs and/or wheelchair users to workplaces may require such additional assistive equipment as ramps, lifts, adapted vehicles, and other WSMDs.
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A thorough evaluation focuses on the individual's physical condition; the functioning and fitting of the WSMD and associated seating system; the individual's current ability to utilize the WSMD (ergonomics and safety) ; the individual's satisfaction with the WSMD; the individual's underlying disorder and associated secondary health conditions/impairments; and assessment of past, current, and future functional needs at home, in the community, and in the workplace.
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From page 68... ...
Providing inappropriate WSMDs can have unintended consequences, such as elevated risk for trips, falls, and collisions; pain due to excessive vibration exposure; injuries due to component failures; soft-tissue injuries, including pressure ulcers; and repetitive strain injuries, such carpal tunnel syndrome, elbow tendinitis, and rotator cuff injuries. A WSMD needs to serve as an extension of the user, becoming integrated into the person's life and facilitating independence and community participation.
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Users of powered wheelchairs must be able to operate the controls safely and judge the device's capabilities given their
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assert the need for a controlled-environment outcome measure using a standardized obstacle course for measuring driving skills, a need not met by existing instruments for evaluating powered wheelchair driving. The Power Mobility Indoor Driving Assessment (PIDA)
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of U.S. wheelchair users with spinal cord injury reported needing ≥1 repairs within a 6-month period; 27.4 percent experienced an adverse consequence as a result of the needed repair; 7.1 percent did not complete the repair; and most repairs were completed by a vendor for powered wheelchairs and by users themselves for manual wheelchairs (Worobey, 2016)
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. This package is designed to train wheelchair service providers, such as clinicians, in six basic wheelchair maintenance and repair skills, although it covers only manual wheelchairs.
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And, given the numerous activities and tasks in which users must engage every day, it is easy to lose track of time and forget to perform pressure reliefs even for those who are aware of the importance of preventing pressure ulcers. ACCESS AND AVAILABILITY Availability of Wheeled and Seated Mobility Devices WSMDs are made available through a complex network that involves a chain of professional providers, funding sources, and manufacturers.
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Groah and colleagues (2014) found that standards of care for the provision of high-quality powered wheelchairs for individuals with spinal cord injury were not being met across payer sources, except at the VA.
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This level of expertise is available only in specialty rehabilitation hospitals and centers, particularly those with expertise in treating spinal cord injuries and cerebral palsy. Ensuring that complex WSMDs are properly configured and their users are adequately trained requires a coordinated interprofessional team approach to service delivery.
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, while there are fewer than 10,000 certified orthotists and/or prosthetists and approximately 8,874 physicians boardcertified in physical medicine and rehabilitation (PM&R) .6 Physical therapy and physiatry require a doctoral degree before an individual qualifies for their board examination; occupational therapy currently requires a aster's m degree but is transitioning toward a doctoral degree; and programs in o rthotics and prosthetics require a master's degree.
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Program objectives are to identify seating and mobility interventions for people with physical disabilities, discuss service delivery practices, explore current research, and understand the features and clinical impact of seating mobility technologies (ISS, 2016)
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. Among users of powered wheelchairs, only 37 percent were reimbursed by insurance for any part of the cost, and only 41 percent received training in the device's use (Iezzoni et al., 2010)
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* Data provided by the Rehabilitation Engineering and Assistive Technology Society of North America.
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This list on the CARF website is not comprehensive as there are clinics that provide wheelchairs to a high standard but are not within the family of CARF-accredited facilities. FINDINGS AND CONCLUSIONS Findings Access to Wheeled and Seated Mobility Devices 3-1.
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3-3. Customizable powered wheelchairs have been shown to improve functioning.
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. Conclusions Access to Wheeled and Seated Mobility Devices 3-1.
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2007. Comparison of mobility device delivery within Department of Veterans Affairs for individuals with multiple sclerosis versus spinal cord injury.
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2015b. Power mobility devices: Complying with documentation and coverage re quirements.
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2004. Durability, value, and reliability of se lected electric powered wheelchairs.
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2002. Factors influencing the decision to aban don manual wheelchairs for three individuals with a spinal cord injury.
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2000. Outcomes follow ing traumatic spinal cord injury: Clinical practice guidelines for health-care professionals.
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2008. Guidelines on the provision of manual wheelchairs in less resourced settings.
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have physical can stand and function intact; impairment and walk to some able to self obesity degree; users propel the spend at least 2 wheelchair hours/day in the wheelchair Ultra- $1,800– Almost all ages (e.g., Used as primary Able to selflightweight $4,000 18 months to 100 or sole mode of propel the (K0005) , years)
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WHEELED AND SEATED MOBILITY DEVICES 91 Need for Life Training Span of and Benefits of Limitations Device Other Adaption Device of Device (Years) Maintenance Considerations Minimal Inexpensive Heavy; 1–3 years Minimal For temporary and readily difficult use or transport available to propel; of people within limited a health care customiz- facility ability Minimal Heavy; 1–3 years Minimal Limited seating difficult options, do not to propel; accommodate difficult to specialized transport seating needs Moderate Offers Expense 3–5 Moderate; Must be training for customized and years requires prescribed by advanced fit and difficulty experienced a licensed/ wheelchair configurability; of getting technicians certified skills easier to approval for medical lift; easier funding professional to propel, essential for those with limited endurance or strength, such as patients with tetraplegia Minimal Can be used Heavy; 3–5 Moderate Often better by people with difficult to years because of served with weight above propel weight of a powered 250 or 350 user wheelchair pounds continued
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From page 92... ...
92 THE PROMISE OF ASSISTIVE TECHNOLOGY ANNEX TABLE 3-1 Continued Cost Requirements Device Range Population Intended Use for Use Powered Wheelchairs Scooter/Power $1,000– Primarily elderly or Supplemental Cognitive Operated $6,000 people with early form of mobility ability to Vehicle onset of progressive for those who operate; arm conditions (e.g., can stand and and hand multiple sclerosis) ambulate to some function intact degree Group 1 $3,000– Primarily elderly, Primarily indoor Cognitive ability Powered $8,000 temporary use, or use to operate; Wheelchair back-up arm and some hand function intact; ability to perform independent weight shift and transfers Group 2 $3,000– Long-term use Cognitive Powered $20,000 for individuals ability to Wheelchair who can still operate; arm independently and some hand weight shift or function intact transfer Group 3 $8,000– Long-term wheelchair Long-term use Cognitive Powered $35,000 users without for individuals ability to Wheelchair effective ability to who cannot operate; arm propel a manual independently and some hand wheelchair, perform weight shift or function intact an independent transfer or ability to weight shift, or propel use hands-free in the community interface Group 4 $10,000– Active indoor/ Long-term use Cognitive Powered $40,000 outdoor long-term for individuals ability to Wheelchair wheelchair users who cannot operate; arm without effective independently and some hand ability to propel a weight shift or function intact manual wheelchair, transfer; better or ability to perform an designed for use use hands-free independent weight outside of the interface shift, or propel in the home; ideal for community active users aWheeled and seated mobility devices are medical devices with wheels that are intended to provide mobility to persons with restricted or no ability to ambulate without assistance from technology.
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WHEELED AND SEATED MOBILITY DEVICES 93 Need for Life Training Span of and Benefits of Limitations Device Other Adaption Device of Device (Years) Maintenance Considerations Minimal Intuitive to use Poor seating 1–5 years Moderate; Requires for support requires additional and pressure regular tire equipment to reduction; and battery transfer; difficult instability maintenance to use in-home, and tipping; or when made large turning for in-home radius presents safety risk in community Minimal Relative Short range 1–3 years Frequent tire, Not durable for ease of use; of only 3–5 battery, and regular users lightweight miles; few hardware of a powered compared advanced maintenance wheelchair with other features, powered such as tilt wheelchairs; or recline can be portable Moderate; Limited seat Not as 3–5 Minimal to need for an functions and durable as years moderate experienced customi- Group 3; licensed/ zability limited seat certified functions medical and customiprofessional zability Moderate; Intermediate Designed 3–5 Requires need for an range and for use in years skilled experienced speed the home technicians licensed/ certified medical professional Moderate; Longest range Expense 3–5 Requires Limited funding need for an and highest years skilled available experienced speed; most technicians licensed/ customizable certified and greatest medical number of professional options; greatest durability
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From page 94... ...
seat seated 1-Ramps Manual 3-Ramps elevation balance 2-Curb-cuts Seating 4-Turning 4-Manual 4-Support 3-Thresholds Functions space standing for 4-Curbs 3-Powered 5-Size 5-Powered standing 5-Steps Seating (width, Device standing balance 6-Stairs Functions length) Manual wheelchairs Standard 1 1 1, 2, 3 1 1 (K0001)
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From page 95... ...
WHEELED AND SEATED MOBILITY DEVICES 95 Carrying: 1-Unable to carry items without impacting mobility Reaching: or 1-Provides function Communication: floor 2-Able to Lifting: 1-Does not level carry 1-Does not support use of support 10 lb extend communication 2-Provides without range of device; Mobility chair- impacting lifting 2-Accommodates Outdoors: level mobility 2-Extends mechanical 1-Americans support or Dexterous range of connection of with 3-Provides function Movements: lifting communication Disabilities variable 3-Able to 1-Requires 6-12 device; Act (ADA) seat carry gross inches 3-Provides surfaces elevation 25 lb motor 3-Extends mechanical 2-Non-ADA above without function range of and electronic pedestrian chair impacting 2-Requires lifting (e.g., charging)
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From page 96... ...
and Extra Heavy-Duty (K0007) Powered Wheelchairs Scooter/ 1, 3 1 1, 2, 3 1 1, 2, 3 Power Operated Vehicle Group 1 1 1 1, 2, 3 1 1, 2, 3, 4, 5 Powered Wheelchair Group 2 1, 3 2 1, 2, 3 3 1, 2, 3, 4, 5 Powered Wheelchair Group 3 1, 3 2, 3 1, 2, 3 3 1, 2, 3, 4, 5 Powered Wheelchair Group 4 1, 3, 5 2, 3, 4 1, 2, 3, 4, 5, 6 3 1, 2, 3, 4, 5 Powered Wheelchair
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From page 97... ...
WHEELED AND SEATED MOBILITY DEVICES 97 Carrying: 1-Unable to carry items without impacting mobility Reaching: or 1-Provides function Communication: floor 2-Able to Lifting: 1-Does not level carry 1-Does not support use of support 10 lb extend communication 2-Provides without range of device; Mobility chair- impacting lifting 2-Accommodates Outdoors: level mobility 2-Extends mechanical 1-Americans support or Dexterous range of connection of with 3-Provides function Movements: lifting communication Disabilities variable 3-Able to 1-Requires 6-12 device; Act (ADA) seat carry gross inches 3-Provides surfaces elevation 25 lb motor 3-Extends mechanical 2-Non-ADA above without function range of and electronic pedestrian chair impacting 2-Requires lifting (e.g., charging)
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