A focus on technologies to ease operation and innovations in existing seating systems help power mobility users move ahead.
by Brittan West
Optimization of free movement and choice of direction represents the most recent and significant improvements among power mobility technologies. These refinements built into existing systems have done much to increase the number of “user-friendly” options that enhance function, safety, and accessibility for today’s power mobility consumers.
The trend toward improving the power mobility user’s experience springs not only from the availability of high-tech innovations, but also from the level of sophistication these user-friendly components offer. This sophistication has helped innovate ease of operation into power mobility devices. New switches and head array systems are among the important advances engineered to provide users with more control for greater ease of operation. David Kreutz, PT, ATP, Seating Clinic Manager at the Shepherd Center, headquartered in Atlanta, says these refinements are driving manufacturers to improve or tweak their electronics to make them increasingly user-friendly.
“The displays that are available on the chairs are more userfriendly,” Kreutz points out. “The diagrams or graphics on the displays begin to explain [to] or tell the patient what mode they’re in, or what will happen if they move the joystick in a particular direction.”
Part of this fine-tuning on the part of manufacturers is owed to the fact that accessories for power mobility devices have grown smaller. Yet even as these components have become downsized,
their ability to help users take advantage of them in activities of daily living (ADLs) has become supersized. Accessories such as mounts for cell phones, mounts for iPads or different tablets, and
drink holders represent only a few of the small feats of engineering that can provide oversized benefits.
In addition to accessories geared to support technologies used by the general population, the integration of Bluetooth technologies into the mobility arena has brought computer accessibility to a larger number of power mobility device users. One significant benefit that Bluetooth offers is mouse emulation, a technology that allows users who may not be able to efficiently use a conventional mouse or trackball to utilize the chair’s joystick to control a computer.
It’s not just high-tech communication accessories that are improving the user experience. The backbone of these products, too, has taken on notable improvements. For example, heavy duty frames that appear in some of the newest product lines are engineered to accommodate weight capacities from 400 pounds and heavier. Sturdier armrests and legrests, coupled with wider foot plates and bases, are also among key alterations that make for an increasingly tailored power mobility solution.
Advances in seat functions, environmental control units, and tires are factors driving some of the most notable improvements in power mobility systems, and each represents a segment of the market
that has helped assisted users get the most out of power mobility devices. Sheila Boyd, OTR/L, ATP, occupational therapy manager for CHRISTUS St. Michael Rehabilitation Hospital and CHRISTUS Dubuis Hospital of Texarkana in Texas, describes the boon these technologies offer. “Seat functions have definitely improved, so we can offer patients the tilt-in-space. Different types of controllers, too, have made access a little easier for them. Environmental control units, which are options on power chairs, can help the patient control the environment in the home setting, such as temperature, televisions, and appliances.”
Boyd also notes flat-free tires offer valuable benefits. “A lot of times wheelchair users were stranded because they had a flat on their tire. Now we have the option to offer flat-free tires, which reduces that risk. This is particularly important if that user becomes stranded in an unsafe environment,” Boyd says.
The seat elevator also plays a versatile role in enhancing mobility for users throughout a variety of age brackets, allowing for participation in family activities and school, and for assistance in independent function—including transfers, turning light switches on and off, getting a glass of water, or retrieving a coat from its hook. In spite of its benefits and noted potential to eliminate the need for a caregiver, Medicare guidelines that limit reimbursement to one power function can stymie funding.
Ability to move safely and confidently through the community is another important consideration. To support this aspect of mobility, manufacturers offer high-speed motor and light packages to improve visibility during the day and at night. Although obtaining funding for lights and other safety packages can be challenging, the need for these technologies to increase visibility when crossing a busy street—as well as the ability to cross the street fast enough—is essential. “Without it, you’re still out there and the cars are ready to go,” says Tamara Kittelson-Aldred, MS, OTR/L, ATP/SMS, Community Medical Center, Missoula, Mont. Kittelson-Aldred works in the facility’s Positioning and Mobility Equipment Clinic for children and youth, and emphasizes how the sometimes harsh weather in the area she services can require mobility devices to push the envelope of performance.
“Performing the necessary ADLs and operating in the climate in which they are performed can present particularly high demands that power mobility devices must strive to meet,” Kittleson-Aldred says. “For my young lady client who lives up in Plains [Montana], it’s an issue of hypothermia. When it’s really cold and she’s using her power chair to go to the grocery store, she wants to get there as fast as she can and back home as fast as she can because she gets so cold.”
Prolonged movement over a range of locations and obstacles is also being encouraged by alternative technologies currently under development. Among these are products designed to transform wheels into a track system, with the goal of providing users with a way to elevate themselves as well as ascend and descend stairs.
Also facilitating prolonged independent movement are improvements in battery design and ease of charging. From lead acid batteries to gel cells, to chargers offering greater ease of use and safety features to prevent overcharging, batteries for power mobility users reflect modest and purposeful changes geared toward ensuring ease of use. Coordinating with medical suppliers and outlining the kinds of demands a power mobility device user’s ADLs will place on a particular battery can assist therapists in pinpointing the type of battery that can meet these demands.
Evaluating the Path to Independence
Establishing an avenue to smooth movement and interaction in the community, particularly among patients affected by conditionssuch as arthritis or multiple sclerosis, can play an integral role in meeting the needs of power mobility users. Scooters can provide a valuable solution to this segment of users.
“Scooters have an appropriate place for individuals who can transfer and have good sitting balance. They tend to be used more for outdoor mobility than indoor mobility, because of their length and turning radius…and the turning radius, unless you’re very petite, [is] pretty large,” Kreutz explains. While a scooter’s length and ride may make the device better suited to outdoor use, it can have utility in a house that can accommodate the scooter and its wider turn radius. Improved throttle levers, outdoor performance and speed, portability, and accessories such as rear view mirrors and weather breakers also enhance the level of independence and safety a scooter offers to a user.
When a scooter is appropriate for a client’s needs, the case for obtaining reimbursement will hinge on justifying the functional disabilities behind the request for the device. Boyd explains, “The client may have had three scooters in a row before they get to the point where they need something different.”
Medicare policy, however, can impact access to specific technology. Medicare’s “in the home” requirement effects more than just Medicare recipients, Kreutz points out. Insurance companies may adopt Medicare policy. These policies, if adopted, prevent individuals access to technology that they rely on for independence in the community. “So if somebody’s living on their own and they can walk very short distances within their home, but they can’t walk within the community, they don’t qualify for power mobility. That can be very limiting for lots of folks with respiratory or arthritic conditions where they might not be able to ambulate for long distances at all,” Kreutz says.
While much of the power mobility evaluations for scooters mirror those of power wheelchairs, special considerations should be made for how the patient will engage in the transfer process to confirm the appropriateness of prescribing a scooter. The ability to stand or perform a type of stand-pivot transfer and maintain good sitting balance is among the prerequisites during the evaluation. Postural alignment and trunk control also play into the patient’s stability, to ensure the device remains upright and does not lean to one side, particularly when driving on side slopes. Good upper extremity strength to control the scooter’s tiller, steer, operate hand controls, and operate switches and speed controls should round out primary items on the evaluation checklist.
What is even more important than the consideration of technologic advances in making the best power mobility decision is the investigation of a patient’s abilities and functional activities. From grocery shopping to work demands, Boyd and Kreutz recommend developing a firm understanding of the patient’s individual goals and daily activities that illustrate each patient’s “story” to provide a clearer, more concise picture of how the patient intends to use the device. This story may feature other factors, including the environment, the caregiver, and the caregiver’s capability to care for the patient. Weight capacities of vehicles and lifts that will be used with the power mobility device also should be considered during evaluations.
Making the Move
As patients choose to move to a power mobility device, they may discover their home is unable to accommodate their new mobility needs, or participation in the community is compromised because
they lack the use of a motor vehicle. But for users making a transition from manual mobility to power mobility, these issues may actually stem from psychological and social barriers, rather than physical environment. One way to overcome these barriers, Kittelson-Aldred suggests, is through facilitation of early mobility. “We are able to do amazing things with early power and manual mobility when [the patients’] parents are open and willing to go for it. Parents see that just because a child has a wheelchair that will let them be more independent, doesn’t mean the child has to stop working on walking.”
Once manual mobility has been ruled out, the next step in transitioning patients and their families or caregivers into power mobility is to begin trialing a power wheelchair that has been set up to closely parallel the device the patient will ultimately use. Providing adequate trial time for the patient to practice with the device in their natural environment bolsters effectiveness, and helps identify the best fit for driving control. Some technologies that are dialed in during this period include head controls to assist children who may encounter challenges using their hands on switches, and joysticks or proportional head controls. Kittelson-Aldred points out that maintaining a power chair that fits the child and can be used on a regular basis to sharpen skills during therapy sessions
also may assist in justifying the purchase of a chair.
A proactive approach in introducing multiple power seat functions to pediatric patients at younger ages can help smooth this process and broaden the foundation for these mobility-based skills, which can include independent skills using a tilt-inspace feature for weight shift or elevating their legs for edema control and the addition of power recline to foster postural control. Judicious use of power recline, particularly in patients with anterior postural tendency who may be at greater risk for developing hyperlordosis, Kittelson-Aldred says, can both improve postural control and can help prevent postural distortion in this patient population. These skills sets, once reinforced at a young age, then allow the child to add to an evolving cognitive range of skill sets, rather than placing dependence on others or neglecting to use power seat functions at all.
After a successful transition to power mobility, a consideration also should be made for how a user’s power mobility needs will be accommodated as they age or their condition progresses, and what types of technologies will be necessary to accomplish this. While a joystick may be ideal in the present, it may not be a feasible long-term option. The integration of electronics that are going to provide the opportunity for change in the future is key to allowing users at every age to maintain their independence.
Funding Power Mobility
Many agencies that fund power mobility devices will put the greatest emphasis for funding approval on the justification for how the device enables an individual to perform better or become more independent in activities. Improving the odds of reimbursement also can rest on the letter of medical necessity (LMN), which requires therapists to consider the LMN’s audience in terms of who will read it on behalf of a funding agency. A key part of composing an effective LMN includes the ruling out of manual mobility, accompanied by an explanation about the inability of manual mobility to serve the patient’s needs. This explanation should be reinforced by an evaluation’s findings, and a comprehensive justification for each component from the ground up.
Relating each of these features and components to the activities performed by the patient, and how each feature will allow greater independence, represents a preemptive step in turning the reimbursement odds in the patient’s favor. Whether the items in question encompass armrests specifically designed to allow access to different desks, tables, or sinks for hygiene purposes, postural supports intended for balance and reaching, swing-away footrests, or swing-away joystick mounts that allow for closer access to a sink or table, an explanation of the purpose behind each component only increases the odds of funding approval.
Kittelson-Aldred also recommends the use of documentation that demonstrates the patient has had experience in a chair similar to the device being requested. The documentation should communicate that the individual is able to drive the device—or exhibiting sufficient potential to do so—and therapists can confidently use their clinical judgment to state that with continued opportunity to practice and enough exposure to the technology, the patient will be able to develop the skills that they will need.
In certain cases, it also may prove beneficial to illustrate all the considerations that have been made prior to the move to power mobility. The ability to become highly functional while in a manual wheelchair with a type of power assist wheel or lever assist wheel also may bode well in these circumstances, as the funding sources are likely to be more open to considering a less expensive alternative.
Since some of the most desirable improvements in power mobility technologies are saddled by guidelines that can limit their availability, therapists may find themselves in an uphill battle to secure funding for these products. However, it is the promise of enhancing a patient’s quality of life that demands therapists remain steadfast in continuing to request them. Furthermore, that same potential improvement in quality of life may also ultimately be key in securing funding for these items, which, themselves, do not bestow freedom, but rather help users achieve it. RM
Brittan West is associate editor for Rehab Management.