by Cynthia Petito, OTR/L, ATP, CAPS
There are a wide range of manual wheelchair frames and power wheelchair bases to choose from that offer custom configurations. Anyone new to wheeled mobility will be overwhelmed by the choices presented during the first visit to a wheelchair clinic. This new end-user, who will be using the mobility product recommended, will look to the clinician to make all the decisions regarding the first wheeled mobility device. This article provides an overview of complex rehab manual and power mobility, and discusses common considerations for clinicians to recommend the most appropriate device. An overview of the insurance coverage criteria is also outlined to assist clinicians with understanding the documentation requirements.
What is the Cause of the Mobility Limitation?
Complex rehab level manual and power wheelchair devices are mostly considered for patients with neurological diseases or injuries. When evaluating a patient for a mobility device, clinicians have to assess the foundational problems that warrant the need for a manual or power wheelchair. The evaluation should not be based solely on the clinician’s observation of the patient’s ability to ambulate. Clinicians must use objective measures to assess the functional limitations in ambulation and mobility, and avoid subjective testing that may lead clinicians to conclude the patient does not meet the criteria for a manual or power wheelchair.
Individuals with progressive neuromuscular diseases can be challenging to evaluate depending on the stage of the patient’s disease process. Clinicians must understand the disease progression in order to recommend the most appropriate device. Traumatic neuromuscular injuries such as spinal cord injuries (SCI) are usually more evident in evaluating mobility needs. With slower progressive diseases such as multiple sclerosis, a new end-user might need a manual wheelchair once lower extremity weakness, impaired motor coordination, gait instability, and falls become problematic. However, this same end-user may need a power wheelchair after several years due the progressed disease process and complete inability to walk. With faster progressive diseases such as Lou Gehrig’s disease (ALS), a new end-user will most likely need a power wheelchair because clinicians have to stay ahead of the disease progression to maintain safe mobility and maximize independence. Furthermore, if the ALS disease primarily affects the upper extremities but the patient can still stand and take steps, power mobility may be indicated because the upper body weakness causes them to become unbalanced or “top heavy” and falls begin to occur. In this case, if the clinician observes the patient ambulating without considering the upper body weakness, the clinician may defer the recommendation of power mobility based solely on their observation and forget to consider the muscle fatigue and falls risks throughout the patient’s day.
Other mobility limitations may occur due to cognitive impairments related to progressive diseases such as Alzheimer’s and Parkinson’s. Both of these diseases impact muscle strength, but also deteriorate cognitive function. Declined cognition may be an indicator for manual mobility when patients experience gait instability and do not have the judgment and safety awareness to prevent falls.
Overview of Complex Rehab Manual Frames and Power Bases
Manual Wheelchair Frames
When considering a manual wheelchair frame, clinicians have to account for the wheelchair frame weight and the end-user’s weight to maximize independent and functional propulsion.
High-Strength Lightweight Manual Frame (K0004)
These lightweight frames are less than 34 pounds and available in various sizes with features such as adjustable-height arm rests and leg rests and individually configured seat heights, seat depths, and back heights outside the standard sizes. They can accommodate an end-user weight up to 300 pounds. Clinicians can consider a high-strength lightweight manual wheelchair for a new end-user under the following criteria:
• The patient can independently and functionally self-propel the wheelchair while engaging in frequent MRADLs in the home that cannot be performed in a standard weight (K0001) or standard lightweight wheelchair (K0002); AND/OR
• The patient requires a seat width, depth, or height that cannot be accommodated in a standard weight (K0001), hemi-wheelchair (K0002), or standard lightweight (K0003), and spends at least 2 hours per day in the wheelchair.
• A high-strength lightweight wheelchair is rarely reasonable and necessary if the expected duration of need is less than 3 months (eg, postoperative recovery).1
An example would be an individual who suffered a stroke and does not have the strength or activity tolerance to complete their MRADLs at the ambulatory level independently and safely.
Ultra Lightweight Manual Frame (K0005)
Ultra lightweight frames are less than 30 pounds. They have an adjustable axle plate not offered on high-strength lightweight frames.
These frames come in adult and pediatric sizes. They are custom fitted and come in a cross-frame style and rigid-frame style. These wheelchairs are the lightest in weight, and they have the greatest amount of adjustability to properly customize the wheelchair for the individual. They can accommodate an end-user weight up to 250 to 300 pounds. End-users who will need this level of manual mobility are not functional ambulators or are completely non-ambulatory; however, they need wheeled mobility to complete all of their MRADLs both inside their home and within the community. Clinicians can consider an ultra lightweight manual wheelchair for a new end-user under the following criteria:
• The patient is a full-time manual wheelchair user.
• The patient requires individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and these fittings/ adjustments cannot be accommodated by a K0001 – K0004 manual wheelchair.
• Documentation supporting the medical necessity for the K0005 includes a specialty evaluation performed by an LCMP such as a PT, OT, or physician with specific training and experience in rehabilitation wheelchair evaluations.
• Description of the patient’s routine activities and degree of independence in the use of the wheelchair.
• The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.1
An example would be an individual who suffered a SCI with paraplegia. For these new end-users, the wheelchair becomes a part of their everyday life in their home and community.
Extra Heavy Duty Frame (K0007)
For patients who weigh more than 300 pounds, these manual wheelchair frames can be considered. However, these frames are typically very heavy, weighing more than 36 pounds. When combining the wheelchair frame weight and the patient’s weight, self-propulsion may not be functional. It is important for clinicians to consider shoulder injuries and other physical demands with patients who have to propel their own body weight greater than 300 pounds.
Manual Tilt-in-Space Frame (E1161-Adult, E1232/E1233-Pediatric)
Tilt-in-Space wheelchair frames come in adult and pediatric sizes, in both folding and rigid frame styles, and in various weights depending on the configuration. The tilting feature allows for up to 55 degrees of tilt depending on the manufacture make and model. When needed, a recline feature can be added to this frame to accommodate patients who are in need of both tilt and recline seating.
There are many ways to configure a tilt-in-space wheelchair depending on the goals for end-users and their caregivers. The most common configuration is for those patients who are totally dependent in their daily care, and need proper positioning and pressure relief during their daily routine activities. Clinicians can consider a tilt-in-space manual wheelchair for a new end-user under the following criteria:
• A standard manual reclining wheelchair will not meet the patient’s needs (eg, sliding, risk of skin breakdown, postural/spinal deformities).
• Justification of features on a tilt-in-space wheelchair that are not offered on a standard manual reclining wheelchair.
• Documentation supporting the medical necessity for the tilt-in-space frame includes a specialty evaluation performed by an LCMP such as a PT, OT, or physician with specific training and experience in rehabilitation wheelchair evaluations.
• The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.1
Power Options for Manual Mobility
Push-Rim Activated Power Assist Device (E0986)
These power-assisted wheels are mounted on the wheelchair in place of the manual wheels. The batteries are integrated in the wheel hub, and a sensor registers the propelling movement that activates the electrical motors. When the patient propels a certain amount of force, the push rims engage the motors to propel the wheelchair. This power option is beneficial for end-users who will be using their manual wheelchair full time in the community or have hills and curbs to negotiate. The power assist feature will address issues with repetitive shoulder motion such as overuse shoulder syndrome. When power mobility is not a consideration, power assist wheels may also be considered for those who have upper extremity weakness and muscle fatigue.
Other Power Assist Products
There are several types of power assist products on the market. One type is a system that incorporates a joystick controller, battery pack, and electric wheels that allow a manual wheelchair to be converted into a lightweight power wheelchair. It is easy to dismantle and ideal for transporting. Another type of power assist product adds a power wheel (third wheel in back of the frame) to the manual wheelchair to propel the wheelchair forward. Both types allow for varying speeds of propulsion, cruise control, and ability to negotiate hills and different types of terrain.
Clinicians can consider recommending power assist products for manual mobility only after the end-user has been using and self-propelling a manual wheelchair for a least 1 year. In addition, the following criteria has to be met:
• Justify why a power wheelchair will not meet patient needs.
• Documentation supporting the medical necessity for the power assist includes a specialty evaluation performed by an LCMP such as a PT, OT, or physician with specific training and experience in rehabilitation wheelchair evaluations.
• The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.1
Power Wheelchair Bases
Power wheelchair bases come in three different drive wheel configurations. They can accommodate end-users who weigh up to 600 pounds. There are manufacturers that offer bariatric power wheelchairs for end-users who weigh up to 1,000 pounds. When evaluating for power mobility, clinicians have to consider the patient’s environments both inside and outside their home, as well as their means of transportation and needs in the community.
(HCPCS Codes are dependent on the weight capacity of the power base and the number of power seating functions included).
Front-Wheel Drive Base (FWD)
A front-wheel drive power base is manufactured with the drive wheel located in the front of the wheelchair base. This base does well in obstacle climbing and overall stability when negotiating different types of terrain. FWD bases are known for fishtailing when driven at high speeds. The turning radius of a FWD falls in the middle when compared to a rear-wheel and mid-wheel drive base. The turning radius of a FWD is typically smaller than a rear-wheel power base, but larger than a mid-wheel power base. Because the drive wheel is in the front of the base, the FWD configuration allows for turns around tight 90-degree corners; however, the end-user has to account for the rear-end of the power wheelchair, which swings around behind them.
Mid-Wheel Drive Base (MWD)
This drive-wheel configuration has the tightest turning radius of the three drive wheel bases. A MWD power wheelchair can turn in a 360-degree circle within the footprint of the wheelchair, which allows for maneuverability in confined spaces inside an end-user’s home. When it comes to outdoor use, the MWD tracks well on unlevel terrain as the drive wheel is in the center of the power base. With six wheels on the ground, end-users who are new to power mobility may feel more stable. In addition, driving a MWD power wheelchair tends to be more intuitive because the drive wheel is under the seat of the individual, creating a center of gravity feel much like ambulatory motion.
Rear-Wheel Drive Base (RWD)
Rear-wheel drive power wheelchairs are known for handling aggressive terrain and performing well at top speeds. The primary disadvantage of a RWD base is the overall footprint for maneuvering indoors and a large turning radius. When considering a RWD base for a new end-user, the clinician must make sure a RWD is appropriate for maneuverability inside the home, as well as work, school, or other environments the individual engages in throughout their day.
Clinicians may consider power mobility for new end-users under the following criteria:
(NOTE: The criteria does not include the power seating functions, seating system, and accessories, which have to be justified separately from the power wheelchair base.)
• Patient’s needs cannot be met with the use of an ambulatory device (cane, walker, crutches), manual wheelchair, power scooter (POV), or non-complex power wheelchair (consumer level).
• Patient needs the power wheelchair to carry out one or more MRADLs inside their home.
• Patient has the cognition to safely operate the power wheelchair.
• Patient’s home environment is conducive for use of the power wheelchair, and the patient can safely drive the power wheelchair inside their home.
• A home assessment has been completed by the supplier.
• Documentation supporting the medical necessity for the power wheelchair includes a specialty evaluation performed by an LCMP such as a PT, OT, or physician with specific training and experience in rehabilitation wheelchair evaluations.
• The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.1
Alternative Drive Controls for Power Mobility
When a patient cannot operate a standard joystick controller with their upper extremities, alternative drive controls have to be considered to maximize independence. Clinicians will have to complete an access site assessment. Michelle Lange, OTR/L, ABDA, ATP/SMS, offers resources, such as her Decision Making Tree for Non-Joystick Driving Methods, to help guide clinicians in evaluating for alternative drive controls.2
There are several types of alternative drive controls to trial with a new end-user. Some include head and chin controls, foot controls, sip-n-puff, switch drive, and fiber optics. Recently, a combination of two alternative drive controls in one unit has become popular. For example, the combination of a head array and sip-n-puff system is now available on the market. In addition, there are proportional and non-proportional controllers, and mechanical and proximity switch drive controllers.
Clinicians will have to match the patient’s function to the proper drive control depending on the strongest and most reliable access site. For example, an individual with quadriplegia may have weak head and neck control. The clinician can trial a head array, chin control, and sip-n-puff system (or the combination of two) to see which type the patient feels most comfortable with and has the most success.
Another example would be a patient with ALS who has absent upper extremity function, neck weakness, but functional foot and ankle range of motion and strength. If the foot and ankle are the strongest and most reliable access site, the clinician will want to consider a foot control for the wheelchair.
Summary
Both new and existing end-users should be informed of all their options and choices in equipment regardless of funding limitations and insurance coverage criteria. Clinicians can learn more about complex rehab technology (CRT) by visiting online resources such as Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), National Registry of Rehabilitation Technology Suppliers (NRRTS), and the National Coalition for Assistive and Rehab Technology (NCART). with disabilities who may need a wheelchair. RM
Cynthia Petito, OTR/L, ATP, CAPS, is founder of the CHAS Group HC Corp, specializing in wheeled mobility, complex seating, assistive technology, home safety, and home modifications to keep individuals living independently in their home. For more information, contact [email protected].
Resources
1. Centers for Medicare and Medicaid Services. (2017). Medicare Coverage Database. Retrieved from https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx. Accessed January 31, 2018.
2. Lange M, Minkel J, Eds. Seating and Wheeled Mobility: a Clinical Resource Guide. Thorofare, NJ: Slack Incorporated; 2018.
3. Lange M. (2017). Decision Making Tree for Non-Joystick Driving Methods. Retrieved from http://www.atilange.com/resources.html. Accessed January 31, 2018.