The Prescriptive Thought Process

sweet teaganThe un-prescribed wheelchair is potentially as harmful and as hazardous as the self-prescribed drug.  It can cause trauma, deformities, disabilities, and other complications that may be irreversible.” (United States Department of Health, Education and Welfare)  How true a statement, as any experienced clinician or equipment specialist working in the seating and mobility industry can attest to.  So what does it take to prescribe an appropriate wheelchair for a client – what is the prescriptive thought process.

Usually, a referral for a seating & mobility evaluation is presented to a clinician (OT, PT) and/or Rehab Technology specialist or the client is presently being treated by a therapist who initiates the process (contacting the physician for prescription).   A brief interview with client or caregivers obtains information such as diagnosis, age, weight/height, past medical history pertinent to seating (past and future surgeries), living environment (home, school and work), client transportation, functional strengths & limitations, goals of client/caregivers to name a few.  The physical assessment/evaluation is performed which can include, but is not limited to the following:

  • Skeletal alignment Issues (flexible vs. structural) of pelvis, spine, extremities, and head
  • Joint range of motion limitations pertinent to seating ( hip, knee & ankle soft tissue flexibility)
  • Muscle tone abnormalities impacting on postural control/function
  • Obligatory primitive reflexes that negatively influence tone and postural control
  • Muscle Strength/ Endurance
  • Abnormal muscle synergies of movement
  • Sensory Limitations – paralysis vs paresis vs sensory processing issues
  • Fine Motor Skills- level of function, visual- spatial, visual-perceptual, handedness
  • Gross Motor Skills- level of function, Head/Trunk control – none, poor, fair, good, N, sitting balance, ambulation and transfer capability (described in detail)
  • Cognitive Capability
  • Vision- acuity, depth perception, visual-spatial skills
  • Auditory
  • ADL (Activities of Daily Living) –hygiene related (bath, brushing hair/teeth), dressing, toileting, transfers
  • Skin Issues- present or past decubiti type & location
  • Mobility: dependent, self-propulsion, power access
  • Internal organ system issues: Respiratory , Cardiac, GI, Renal, secondary dx
  • Environmental Issues or Specific Needs: Within home, school or work (ex. Pre-school child during circle time at short table to engage with peers)
  • Transportation Limitations
  • Future Growth or other physical changes

With the information from the physical assessment the clinician formulates a problem list, prioritizes the list and develops seating goals to address the client’s issues. The chair evolves from this information obtained through the assessment process.   During the assessment both therapists and equipment suppliers are considering multiple equipment options to address adequately the problems they encounter with the client.  If a client displays independent mobility capability that drives the choice of frame (self- propulsion versus power mobility with specific input device(s), lightweight vs. ultra-light manual chair, front wheel vs. rear wheel placement, one arm drive,  or power assist ). Trials usually are performed to ensure appropriate choice of frame.  Frame features need to be considered with skeletal and joint range of motion limitations (seat to back angle adjustments, front hanger length), significant weight issues, respiratory, feeding, GI, renal or skin issues (tilt, recline capability) to name a few.

If the client is incapable of independent mobility within the 5 year period of seating in the new chair, then the team needs to address improving postural control of the trunk & head as well as UE function, through seating components and a dependent frame choice.   This system needs to provide not only support, but comfort, pressure relief and promote an increase in sitting tolerance. If the funding source is Medicare the team must follow the algorithmic process for determining a mobility deficit as of 7/2005.   Mobility Assistive Equipment (MAE) includes canes, crutches, manual wheelchair, scooters and power wheelchairs. National coverage determination states MAE is reasonable and necessary for a beneficiary who has a mobility deficit sufficient to impair their participation in mobility-related activities of daily living (MRADL’s) which can include toileting, feeding, dressing, grooming, and bathing in customary locations in the home.  Does the beneficiary have a limitation that impairs their ability to participate in one or more MRADL’s in the home (independently, safely, or timely).  In this process canes, walkers, gait trainers are considered if the use of this device improves independence safely and timely.  If not then a manual wheelchair is considered based on specifics such as the beneficiary’s ability to self- propel (UE strength/coordination/endurance, as well as cognitive capabilities (safely).  Specific client limitations/strengths are used to justify frame specifications as well as each seating component (muscle tone, skeletal limitations/deformities, muscle strength/ endurance, coordination).  Wheelchair parameters, such as seat to floor height, wheelbase depth, front rigging adjustments, tilt or recline all must be justified for funding sources.

When considering dependent wheelchairs, the Convaid Company has a line with diversity.  The fixed tilt options include the EZ Rider(10*), Cruiser (30*) and Metro(30*).  The EZ Rider can be used for clients with limited functional ambulation secondary to limited endurance, strength, respiratory compromise, balance issues and/or intellectual limitations where safety is an issue.  Clients usually are able to transfer in and out of the EZ Rider independently or with minimal assistance and demonstrate good head and trunk control. This chair comes standard with Convaid’s self-tensio seating system. This unique self-tensioning system has 3 key features that occur when load is introduced:  the frame actually expands, and the upholstery and underlying mesh tighten providing a firm base of support for the pelvis. The tension adjustable back allows for individual adjustment to the pelvic sacral area and thoracic spine to facilitate a more upright posture.  If additional support is needed at the trunk secondary to muscle weakness of the spine soft adjustable lateral trunk supports with strap, H harness, or full torso chest vest can be added.  Planar seating to handle the mild slide of the pelvis forward into a pelvic tilt can be addressed with the position cushion or possibly the align or support cushion.  Also, zipper pockets in the seat and back upholstery allow some modification with foam.

The Cruiser with fixed 30* seat angle from horizontal makes independent transfers a bit more difficult, but provides more anti-gravity support for the client with greater postural limitation of the torso and head.  The Cruiser options include: 1) the Cruiser Classic with self-tensio upholstery with textilene (improved air flow) or cordura fabric, 2)the Planar option with solid seat insert with cushion choice as well as a planar back with chest, torso and head attachment choices and 3) Scout Cruiser (all terrain version) with Anatomical Back, heavy-duty upholstery, and knobby tires.

For clients who need adjustable tilt for a variety of reasons including pressure relief, feeding/swallow assistance,  anti-gravity positioning to assist with limited trunk and head control, improve respiratory status, and visual regard,  increase sitting tolerance/comfort, or for rest periods Convaid has the Rodeo, Safari or Trekker.  The Rodeo adjusts 5-45* of posterior tilt and has 20* seat to back angle adjustment as well.  It has firm, adjustable, fold down trunk supports with chest strap or soft padded adjustable lateral support,  occi headwing headrest, optional choice of 3 seat cushions (support, align, or position which can address mild extensor thrust, mild windswept or abducted lower extremities) or medial/lateral thigh supports that address the thighs. It comes standard with elevating leg rests with one piece adjustable footplate.  Both the Rodeo and Trekker have a clam shell fold which allows for the seating to remain on the frame, unless after- market seating is used with the Trekker.  All frames are WC 19 crash tested, extremely lightweight, durable and fold compactly into car trunks.

The Trekker has adjustable tilt ( 5* anterior  to 45* posterior tilt), 170* of recline adjustment, 180* reversibility of seating system on frame (carriage ) and can accommodate after marketing seating with the seating module or Convaid seating with choices such as contoured or planar cushion, width adjustable trunk supports, butterfly harness, adjustable wing head support or curved head support with universal head support mount.  This frame provides much more aggressive seating choices for the moderately involved client who is unable to access independent mobility but needs support for pelvis, trunk, and head.  For ventilator dependent clients, the ventilator/suction machine hard tray can be mounted under the seating module, oxygen tank can be stored on frame with tank holder and the LTV ventilator can be mounted to the side of frame for easy viewing.  The 180* reversible seating provides caregiver clear view of the client for safety and social interaction.  In summary, if a client lacks independent mobility capability, but requires minimal to moderate seating support as well as a lightweight , collapsible, easily transportable system with WC 19 crash testing Convaid needs to be considered.

 

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