You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > REHABILITATION PROTOCOLS Seating Evaluation and Wheelchair PrescriptionArticle Last Updated: Jul 21, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
 
Author: Pamela E Wilson, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado; Medical Director of Assistive Technology, Medical Director, Spinal Defects Clinic, Training Director, Pediatric Rehabilitation Fellowship, The Children's Hospital Pamela E Wilson is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation Coauthor(s): Michelle L Lange, OTR, ABDA, ATP, Owner, Access to Independence; Benjamin R Mandac, MD, Medical Director of Pediatric Rehabilitation, Clinical Assistant Professor, Department of Pediatrics, Santa Clara Valley Medical Center Editors: Virginia Simson Nelson, MD, MPH, Chief, Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Division of Pediatric and Adolescent, Dept of PM&R, University of Michigan; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; Rene Cailliet, MD, Professor-Chairman Emeritus, Department of Rehabilitation Medicine, University of Southern California School of Medicine; Former Director, Department of Rehabilitation Medicine, Santa Monica Hospital Medical Center Author and Editor Disclosure Synonyms and related keywords: assistive device, wheelchair, mobility device, mobility assistive equipment, MAE, wheelchairs, scooters, power wheelchairs, electronic aides to daily living, EADLs, DME, durable medical equipment INTRODUCTIONSection 2 of 11
 
Wheelchair seating and mobility is a technical and specialized area of rehabilitation medicine. One must understand the unique characteristics of the individual and the current technology in order to choose the best type of mobility assistive equipment (MAE). Successful delivery of a wheelchair and seating system begins with making the determination that the patient has a mobility impairment that requires the use of an MAE. Rehabilitation principles apply in the decision-making process. The needs of the patient, as well as of the caregiver, are paramount. Goals include facilitation of mobility, positioning, support, adaptations to temporary or permanent conditions, and optimization of function. An appropriately used system that is accepted by the patient and caregiver is an indicator of a well-developed system. EQUIPMENT CATEGORIESSection 3 of 11
Positioning and mobility are used to augment function in individuals with physical, sensory, and/or cognitive limitations by providing opportunities to be as independent as possible. This is achieved by providing the following type of equipment:
ASSESSMENT AND TEAM MEMBERSSection 4 of 11
Assessment can occur in a number of settings, including a specialty medical clinic, a supplier's office, or a natural environment (eg, classroom, work place). The members of the team depend on the complexity of the individual being evaluated. Team members can include the following:
The current working model is for teams to use a family-centered approach in which the client and family are incorporated into the decision-making process. This is a critical element in ordering equipment because the end user must be satisfied with the end product to ensure its use. The clinic model has the disadvantage of requiring the client to leave his or her natural environment but, at the same time, provides an opportunity for a group of well-qualified personnel to demonstrate and recommend appropriate equipment. Optimally, the client and family can see and play with different styles of equipment. The other options are the DME provider's office or the natural environment (eg, work, home, school). The natural environment provides an opportunity to truly assess how equipment can be used. Existing barriers can be identified, and their impact on mobility and function can be realistically examined. SEATING AND WHEELCHAIR ASSESSMENTSection 5 of 11
The positioning and mobility assessment includes a medical, psychosocial, and functional history, along with a complete physical examination. Key elements include the following:
SPECIFIC ASSESSMENT CONSIDERATION FOR MOBILITY ASSISTIVE EQUIPMENTSection 6 of 11
Walkers and gait trainers Walkers and gait trainers often provide independent short-distance mobility, but they are rarely appropriate for long distances or outdoor use. This requires too much effort and time for the user. Keep in mind the need for long-distance mobility. Adaptive strollers Many families prefer an adaptive stroller to a manual wheelchair. Manual wheelchairs typically do not provide adequate support for the very young child. Strollers have growth potential, but the equipment can generally only be used for 1-3 years. Manual wheelchairs An extensive variety of manual wheelchairs is on the market, each with different available options. These chairs can be designed for either independent or dependent propulsion. Manual wheelchairs are available in either a folding or rigid frame design. Rigid frames tend to be lighter weight and more efficient. These frames have more adjustability in personalizing the fit and responsiveness of the wheelchair. Aspects such as rear wheel position, camber, and seat dump can be incorporated. Folding frames may be easier for families to load, but they are heavier and have more parts. Optimizing the position for propulsion is critical for endurance and for minimizing the risk of repetitive stress injuries. Another manual wheelchair type is the tilt-in-space wheelchair, which is used for clients who need assistance with positioning and mobility. They tend to be heavier and more difficult to load into automobiles. Power mobility devices Power mobility devices (PMDs) include power-assist wheels, scooters, and power wheelchairs. Scooters tend to be less expensive and are easy to transport, but they lack supportive seating. Power-assist wheels can be added to a manual wheelchair, and the chair is easy to transport; however, a certain level of coordination is needed for operation. Power wheelchairs can be fit with a variety of actuator options, including tilt, recline, and seat elevation. The 3 traditional configurations are rear wheel, center or mid wheel, and front wheel. Assistive technology devices can be adapted to the wheelchair. Newer, high-technology wheelchairs are being developed and include the IBOT, which has the ability to navigate stairs using a gyroscope system. Seating The goals of seating must include the following rehabilitation concepts:
Data collection Obtaining information in 3 critical areas is necessary to help define and determine appropriate seating. These include physical and disability characteristics, functional skills, and lifestyle and preferences. Information categorized in the physical and disability characteristics domain includes the following:
Information on functional skills and cognition should include the following:
Information about lifestyle and personal preferences should include the following:
Physical examination A physical examination and postural assessment are necessary components of the evaluation of the patient's condition. The following data should be obtained during the hands-on evaluation. Using a systematic approach helps achieve a skilled and thorough examination. Begin with a general inspection and observation, which should include assessment of the following:
The musculoskeletal examination should include assessment of the following:
The neurological examination should assess the following:
The functional examination should assess the following:
After all data are synthesized, the goals for a seating system can be identified. The goals should be prioritized so that when goals conflict, the basis for compromise is understood and communicated clearly to all parties involved. One example is with deciding which cushion to use. The primary goal of a proper cushion is to prevent pressure sores; however, it may be equally important for the cushion to be lightweight. Otherwise, the patient may not use it. A clear statement of goals and consensus surrounding the goals greatly simplifies the selection of the device because only devices with the necessary features need to be considered. Documenting the process can be extremely effective in justifying to the third-party payer why the particular device was selected and why other less expensive devices are inadequate for the stated medical goals. The seating device can usually be obtained through a DME dealer. In some cases, it may be provided by an orthotist, rehabilitation technologist, or a rehabilitation engineer, particularly if the device is fabricated especially for a given patient or requires some specialized custom feature. For commercially available seating systems, the dealer is usually a helpful resource on which equipment is available to meet the needs identified. The dealer can suggest products from different manufacturers and explain how different products may be combined to produce a better result. He or she can also provide information on durability and reliability and should be able to advise both the patient and the therapist on which options are reimbursed by the third-party payer. Most third-party payers look to the physician for the medical basis for providing a seating system. The physician is best qualified to document the patient's current medical status, the prognosis for the underlying diagnosis, the medical goals for the seat, and the implications of improper seating. The physician is also expected to provide information on whether surgery or other medical procedures are planned that may affect the use of the seat. The physician or health care professional is often responsible for generating a letter of medical necessity. Components of a typical prescription for MAE are as follows:
REIMBURSEMENT TRENDSSection 7 of 11
The trends for reimbursement for seating systems seem to be headed in opposite directions. As the benefits of seating have become more widely accepted, individuals find it easier to have the devices paid for under their insurance coverage for DME; however, the current emphasis in health care on reducing costs is causing private insurers to eliminate high-priced services, such as DME and seating, from their coverage. The policies of public agencies, such as Medicaid, vary from state to state in regard to coverage and the method by which they calculate rates of reimbursement. In some cases, a provider may be reimbursed at the retail cost of the seat, whereas, in other locations, providers may be reimbursed at retail cost less a substantial discount. The obvious effect of coverage limitations is that some individuals are able to acquire needed seating devices, while others are not; however, the effect that reimbursement policies have on the quality of the products delivered to patients is less obvious. Because most providers are not reimbursed separately for the time they spend to provide a seat, their time and other business expenses are reimbursed only to the extent that they generate some profit from the sale of the seat. Effective seating is reflected primarily in the service provided by qualified professionals, rather than in the purchase of any particular product. Reimbursement policies that focus on the price paid for the product undermine the service delivery system and can result in the purchase of a seat that may be inadequate to meet the needs of the patient. When professionals recommend a seating system and third-party payers consider reimbursement, it is important to keep in mind that cost consciousness is defined best as value-conscious, rather than just price-conscious; however, this trend is not likely to be reversed until the industry can establish formal training and certification programs, which will enable patients and third-party payers to distinguish providers qualified to deliver high-quality seating services. COMPONENTS OF WHEELCHAIRS USEFUL IN PRESCRIPTION WRITINGSection 8 of 11
RESOURCES AND CURRENT MEDICARE GUIDELINESSection 9 of 11
The 2005 Medicare guidelines The restructuring of the Center for Medicare and Medicaid divided the country into 4 geographic regions, with each having a DME carrier that makes decisions on equipment. The new guidelines are based on the development of functional criteria for equipment of medical necessity. The following statements are components adapted from the new guidelines:
The wheelchair and seating industry continues to evolve. Experience, economics, and consumer needs drive the changes in the industry. More information is readily available through professional groups, such as the Rehabilitation Engineering Society of North America (RESNA) and the Paralyzed Veterans of America (PVA). Information is also readily available over the Internet. A search yields many sites on wheelchair and seating, but many sites are primarily commercial in nature, not truly informational. Introductory Internet sites include RESNA and WheelchairNet. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Seating Evaluation and Wheelchair Prescription excerpt Article Last Updated: Jul 21, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||
