Wheelchair Basics:form echoes functionMeg Allyn Krilov, M.D.Michele D. Mills, MA, OTR/LWilliam C. Tobia, RPh

The Goals of Wheelchair Prescription

• Maximize mobility and functional capacity

• Prevent morbidity• Provide proper measurement and

ensure safety• Maintain physiological function• Promote participation in ADLs (BADL,

MRADL, and IADL)

ELEMENTS OF PRESCRIPTION

Medical History

Physical Capability

Abilities/Impairment

Medicare Rules

The In Home Rule:• Patient must have difficulty mobilizing

in their home to complete Mobility Related ADLs (MRADLs)

• Patient must be unable to perform MRADLs with cane, walker, or crutch in order to qualify for a wheelchair

• Community Mobility is not Medicare’s primary concern

Assuring Appropriate Fit

• In order to promote optimal seating and positioning a patient must be properly measured and fitted for a wheelchair

Types of WheelchairsMedicare K CODES • K0001 = Standard Wheelchair• K0002 = Hemi Wheelchair• K0003 = Lightweight Wheelchair• K0004 = High strength

Lightweight Wheelchair• K0005 = Ultralightweight High

strength Wheelchair

Types of WheelchairsMedicare K CODES • K0006 = Heavy Duty Wheelchair• K0007 = Bariatric Wheelchair• K0009 = Other Manual Wheelchair• K0010 = Standard Weight Frame

Motorized Wheelchair• Medicare pays to rent for the first

10 months, then becomes purchase.

Wheelchair Featuresand Considerations

WHEELCHAIR WEIGHTS

• Standard (Steel) 40-65 lbs.• Lightweight (Aluminum or steel)

30-35 lbs.• Ultralightweight (aircraft quality

aluminum) <30 lbs.• Titanium <25-15 lbs.

Light Weight and Ultra lightweight Chair Types

• Decreased weight • Ease of adjustability • Decrease in repetitive strain

injuries with prolonged use• Ability to lower seat-to-floor height• Better hand contact with push rim• Improved efficiency with

propulsion.

Ultra Lightweight

Frames – Folding

Frames - Folding

• Easy to transport• Heavier than rigid

Frames - Rigid

Frames - Rigid

• Can be difficult to transport• Lighter than folding frame• More durable

Frames - Titanium

• Enables self propulsion for patients with decreased strength

• Lighter for transport• Durable • Corrosion/abrasion resistant

Sling vs. Solid Seat

SLING SEAT

• Pros• Easy to fold• Easy to clean• Light Cons• Promotes perspiration• Promotes poor posture - posterior

pelvic tilt, hip IR/Adduction

Solid Seat Base and Solid Seat InsertPros• Firm• Promotes postural controlCons• heavier• harder to fold

Seat width - too narrow

• Difficulty with transfers• Promotes skin pressure • Danger of pressure ulcers on

greater trochanters• Uncomfortable

Seat width - too wide

• Promotes unequal weight distribution on ischial tuberosities

• Promotes shearing• Promotes back and shoulder

pain• Leads to difficulty with self

propulsion

Seat depth - too short

• Increases pressure on distal thigh

• Alters weight distribution• Wheelchair may tip over

Seat Depth - too long

• Promotes sacral seating• Promotes posterior pelvic tilt• Promotes skin pressure in the

popliteal fossa

Seat Height

• Consider mobility requirements and transfers

• Lower if utilizing lower extremities to propel

• Too low, there is increased pressure on buttocks

• Too high, difficulty with transfers, wheelchair may not fit under table.

RECLINE• Recliner

Recline• Overall length of wheelchair is longer

a full recliner reclines to 180 degrees• Difficult to propel - in its upright

position it is 6” longer than a standard wheelchair

• May promote shearing during positional changes

• When reclined, does not enable end user with an adequate view of the environment

Tilt-in-space

• Tilt-in-Space

Tilt-in-space

• Entire seat and back tilt as single unit maintaining original angle.

• Minimal to no shear• For effective pressure relief, tilt must

be >45 degrees

Tilt-in-space: Advantages

• Alleviates shear• Enhances postural control• Decreases effects of gravity that

may lead to spasticity• Maintains seating position

during weightshifts• Has a tight turning radius

Tilt-in-space: Disadvantages

• No ROM benefits• Difficult to self perform pressure

relief• Urine may run backwards from leg

bag during tilt.• Difficult to perform catheterization• Items on UESS may slide off• Increases height of wheelchair

Combining recline & tilt• Useful for patients at risk for

pressure ulcers, orthostasis, and hip flexion contractures

• Assists with achievement of weightshifts

• Enhances overall seating and positioning for patients with complicated seating and positioning requirements

• Adds weight, width and bulk.

Backrests• Provides balance support • Provides freedom of movement• Higher backrest, provides more

support, but contributes to less freedom of UE movement

• Lower backrest promotes freedom of movement, but offers less support

• If backrest is too low, it may contribute to decreased trunk stability

Armrests

Desk Arms

Full-length arms

Adjustable arms

Fixed height arms Removable arms Flip back arms

Armrests

Maintain trunk balance and comfort during propulsion

Armrests-positioning

• Too High: poor posture, shoulder elevation and pain, will not fit under table.

• Too Low: poor posture, increased trunk flexion, may compromise respiration.

Wheels

• Mag - heavier with less shock absorption

• Spoke - lighter with better shock absorption, easier to propel but more maintenance

Tires

• Pneumatic with airless insert - rubber inner tube. FLAT FREE

• Pneumatic - air inner tube, light, smoothest ride, flats

• Solid rubber - durable, heavy, harsh ride on rough terrain, no flats, primarily indoor use

Camber

• Definition: The angle that the wheel makes with the vertical axis - between 2-12 degrees

• Advantages: increased stability, easier to propel at fast speeds and easier to turn.

• Disadvantages: increased width and increased wear and tear on tires.

Sports Wheelchair

• Example of Camber

Casters

• Small - tighter turns and greater curb clearance

• Large - smoother ride and better on rough terrain

Handrims

• Aluminum - good friction• Friction-coated - for impaired hand function• Projection knobs increase weight and width but enable self propulsion for patients with

decreased grasp

Foot rests and Leg rests• Swingaway detachable: most commonly

prescribed.

Elevating legrests: used as an aid for improving LE circulation and minimizing edema *when used with tilt

One-piece footboard / foot box: with LE contractures or malformations

Adjustable angle footplates to accommodate contractures

Foot rests and Leg rests

• Too high - increase pressure on ischial tuberosities

• Too low - feet will hit floor, drag on curbs, and sidewalks

Brakes (wheel locks)• Toggle lock (most common) :

push to lock or pull to lock.• Scissor: on sports wheelchairs• Extensions -standard on one-

arm drive so patient can reach across and operate wheel lock on opposite side of wheelchair using only one hand

Cushions

• Foam - heavy, but provides positioning and pressure relief

• Gel – heavy, but provides pressure relief, stability and positioning

• Air (Roho) – provides pressure relief Requires Careful Maintenance!

Is not for everyone!• Custom Molded

CushionsExamples of Common Cushions

Cushions

Pressure mapping

Headrests

• Adjustable for support

Lateral Supports

• Provide trunk support

HIP GUIDES

• Prevent pelvic migration laterally and keep patient centered in seat.

Putting it All Together: Headrest, Lateral Supports, and Hip guides

Pommel / Abductor

• Prevents scissoring and keeps femurs in neutral alignment

• May promote pressure on groin if patient is not properly positioned

Upper Extremity Support Surface (UESS) / Lap tray

• Support and positioning device• Promotes activity performance• Can be difficult to justify with

some insurances

Harness and Seatbelt • Harness for postural alignment.• Seat belt to prevent pelvic tilt

and rotation

Anti-tippers

• Anti-tippers to prevent backwards tipping of wheelchair.

Power wheelchair vs. scooter

ScootersAdvantages• Highly desired among patients• Appear less disabled (as per patient

report)• Can be disassembled for transport in carDisadvantages• Increased turning radius• Tippy on rough terrain• Does not fit in elevators or standard

apartment setting

Power Wheelchair

• Requires letter of medical necessity (LMN)

• Requires a reliable motor output to operate the powered mobility vehicle

• Requires screening of cognitive, visual, and auditory skills

Power Wheelchair

Advantages• Promotes mobility for patients with

complex conditions• Can fit in elevators and standard

apartment settings • Can be customized to meet patients

seating and positioning requirements• Promotes participation in “in-home”

BADLs and MRADLs

Goals of Prescription

• Maximize mobility and functional capacity

• Prevent morbidity• Maintain physiological function• Promote participation in ADLs (BADL,

MRADL, and IADL)

Case Study P.A.P.A. is a 19 year old male with diagnosis of T6 paraplegia

sustained postoperatively in the Dominican Republic during scoliosis surgery.

Assessment• ROM: BUEs WNLs AROM & PROM BLES Contractures at Hips and knees• Tone: BUES Grossly Intact BLES Hypertonicity

Trunk Mild Hypotonicity• Strength: BUEs Good 4/5

BLEs – unable to fully assess due to spasticity• Coordination: Grossly Intact• Sensation: Grossly Intact• Balance: Static Short Sitting Balance Fair + Dynamic Short Sitting Balance Fair

Case Study P.A. continued• Vision / Hearing: Intact• Skin Integrity: hx stage 3 pressure ulcer on sacral region,

healed with darkened skin over region• Cognition / Perception: Grossly Intact• BADL: Independent (Self Catheterizes)• Performs Push-up Transfer• IADL: Independent• MRADL: Performs all ADL from Wheelchair• Accessibility: Lives in Accessible Apartment with Family• Vocational Goal: Attend College• Weight 125 Height 5’4”

What type of wheelchair would you prescribe?What are key features for consideration?What type of seat cushion is indicated?

Case Study R.H.RH is a 74 year old divorced male with diagnosis of COPD,

Emphysema, Chronic Systolic Heart Failure, and CAD with Ejection Failure of 25%, DM Type II

Assessment• ROM: BUEs WFL AROM & PROM BLEs WFL AROM & PROM• Tone: Intact Trunk & Extremities• Strength: Good 4/5 Trunk & Extremities• Coordination: Intact• Sensation: Impaired Light Touch on Bilateral Feet• Balance: Static & Dynamic Short Sitting Balance Good Static & Dynamic Standing Balance Poor• Vision & Hearing: Grossly Intact• Skin Integrity: Intact• Cognition / Perception: Grossly Intact

Case Study R.H. continued• BADL: Modified Independence with Dressing, Bathing and light

Meal Preparation using DME and Adaptive Devices• Transfers with Supervision – Contact Guard• IADL: Assistance from HHA 3 days 4 hours weekly (Laundry,

Shopping, Household Maintenance, and Cooking)• MRADL: Ambulates with Rollator Walker due to decreased

endurance and increased fatigue, uses oxygen via nasal cannula

• History of falls while performing MRADL within the home• Lives alone in private home with accessible entrance• Travel: Ambulette Service• Weight 200 lbs Height 5’11”• Vocational Goals: RetiredWhat type of wheelchair would you prescribe?What are key features for consideration?What type of seat cushion is indicated?

Case Study R.E.RE is a 69 year old female with diagnosis of CVA with

Left Hemiplegia and COPDAssessment• ROM: RUE & RLE WNL PROM & AROM

LUE PROM moderately limited all joints LUE AROM No Volitional Movement LLE PROM WFL LLE AROM No Volitional Movement• Tone: LUE Moderate Hypertonicity LLE Moderate Hypotonicity Trunk Mixed Abnormal Tone• Strength: RUE & RLE Good 4/5 LUE: 0/5 LLE 0/5

Case Study R.E. continued

• Coordination: RUE Grossly Intact• LUE Severely impaired• Sensation: RUE, RLE, Trunk Intact• LUE, LLE, Trunk Impaired• Balance: Static Short Sitting Balance Fair Dynamic Short Sitting Poor Balance Poor Static Standing Balance Poor Dynamic Standing Poor• Skin Integrity: Sacral Pressure Ulcer Stage 2, Left Ischial Pressure Ulcer Stage 2-3• Vision & Hearing Grossly Intact• Cognition: Intact• BADL: Moderate to Maximum Assist from Husband• IADL: Maximum Assist from Husband and Daughter

Case Study R.E. continued

• MRADL: Non-Ambulatory, Performs all ADL in Manual Wheelchair, Dependent on Family for Mobility Indoors and Outdoors

• Sitting Position: Left Side Head, Neck, and Trunk Leaning with Trunk Rotation

• Lives with Husband in Accessible Apartment Building with Elevator

• Vocational Goal: Retired Since CVA• Weight 160 lbs Height 5’3”What type of wheelchair would you prescribe?What are key features for consideration?What type of seat cushion is indicated?

Conjoined Twins: Mobility Challenge

Family Goal: Promote Independence in MRADL

Promoting Mobility Without Dependence on Mom

Promoting Participation in the Environment

Look out world…Independence!

References

Biodynamicshttp://www.biodynamics.us/index.php, accessed 10/17/14

Cooper, RA: Wheelchair selection and configuration, New York, 1998, Demos.

Garstang, SV, Rand, R: Wheelchairs and power mobility. In PM&R Knowledge Now.http://me.aapmr.org/kn/, accessed 10/20/14

References

Koontz, AM, et al: Wheelchairs and seating systems. In Braddom, RL, editor: Physical medicine and rehabilitation, ed. 4, 2011, Philadelphia.

NHIC: Power Wheelchairs and Power Operated Vehicles - Documentation Requirements

http://www.medicarenhic.com/viewdoc.aspx?id=505, accessed 9/30/10

References

• RESNA: Rehabilitation Engineering and Assistive Technology Society of North Americahttp://www.resna.org/, accessed 10/1/14

Wilson, PE, Kishner, S: Seating evaluation and wheelchair prescription. In Medscape.http:emedicine.medscape.com/article/318092-overview