The list of powered mobility devices available seem to be growing weekly, as new scooters, motorized and power wheelchairs and push rim devices are offered by vendors from both established and new companies.
As patients' ambitions grow higher and technology advances, a physical therapist needs to navigate through all the choices and decide what's best for their clients, taking insurance and other factors into consideration.
Scott Weiss, DPT, ATC, CSCS, owner and clinical director of Bodhizone for Human Performance & Sports Physical Therapy, PC, with four offices in New York City, says the practice takes the entire individual into account when making these decisions. Plus, being in an urban environment, he looks for devices that can handle multiple terrains.
"Everything from medical diagnoses, age, weight, intended use, ambitions, transfer status, limitations and the type of environment they live in are all vital in the decision making progress," Weiss said. "One unit does not fit all. Another main focus we have is cost. Some people in New York have the ability to purchase new PMD's without having to go through the insurance model. This being the case, we can really be more specific to their individual needs and receive the newest quality device. On the other hand, patients not as lucky usually get what device they need not exactly what they want."
Theresa Berner, MOT, OTR/L, ATPan occupational therapist and rehabilitation clinical manager at Ohio State's Wexner University Medical Center, says a challenge has been that power mobility policies and reimbursements have experienced drastic changes the past several years.
"Clinicians have had to work hard to keep up with the changes to better understand how to advocate and the wheelchair suppliers have had to make continual adjustments with reimbursements and methods to deliver care to their clients," she said. "Among all these changes the consumers are caught with limited choices in equipment and in some cases suppliers to work with. As a result we are seeing consumers getting frustrated with the system that should be making it easy to provide equipment that enables mobility for better participation in life."
Berner adds that it is essential for the therapists to understand current models so they can maximize resources for their clients and direct them toward the best resources for their needs.
"Because there are so many components of a power chairs available the therapist needs to pay attention to the features of a chair," she said. "When ordering power chairs a patient has many choices and selections. If a power chair is being offered with minimal selection features then it is most likely not going to be a successful outcome."
Things to Consider
According to Seth Kress, MPT, a physical therapist at Loyola University Medical Center in Maywood, Ill., when looking at power wheelchairs a therapist needs to understand the size and options of the base. Having a chair that is able to come in a variety of sizes and have adjustments is essential in the fit and function of the equipment.
Another area is to understand the footprint of the chair, the area of space the chair takes up and how much navigation the chair requires.
"When I look at the footprint of the chair I pay attention to the placement of the front and rear casters," Berner said. "Large rear casters make it difficult to navigate in smaller spaces such as a bathroom when larger front casters make it difficult for stand pivot transfers."
Two options for leg rests are swing away and center mount. A center mount foot plate is nice because it allows the person to maintain stability under the legs and sit in a good midline position. A drawback of a center mount foot plate is that they may be difficult to flip up for a transfer. A final thing to be aware of with center mount footplates is that they may prevent a person from backing up to the edge of the seat for a sit to stand transfer.
Arms rests should support the hanging elbow and are good components for taking weight off of the body when sitting. The length of the armrest is important if a patient needs to use the distance for sit to stand. Back rests should be the appropriate height to support the individual and have adjustment so that the patient is not being pushed forward and sitting on the edge of the chair.
The Voice of the Patient
According to the physical therapists surveyed, patients should be the central focus of the evaluation and they should participate in the entire process of choosing a powered mobility device.
"I believe that we have not engaged patients enough in the process and it is essential that their voce be heard. The standard of practice should be that the patient, therapist and wheelchair supplier all collaborate as partners in a patients care," Berner said. "Therapists are there to guide and advocate for the patients and patients need to take time to understand their choices. If we continue to limit product options and reduce consumer's choices then we are not living up to our oath as therapists."
For example, during the power wheelchair evaluation process, Berner says it is imperative to have trials and allow patients to experience different chairs before they select a chair.
"If a therapist is in an area where they do not have access to equipment or a good wheelchair supplier, then they need to reach out to their colleagues and help the patient get to a wheelchair clinic," she said. "There are therapists that have advanced experience in power mobility and have proven that with obtaining advanced certification such as an assistive Technology Professional (ATP) and Seating and Mobility Specialist (SMS). These therapists should be used as a resource to others to assist with the process of power wheelchair selection."
It's important, Weiss agrees, to let the patients have a role in the decision in some way, shape or form.
"When they are bound by insurance and economics we try to show patients two to three different models that will be covered so they get to be part of the decision making process," he says. "We do ensure that this population will get what is needed but maybe not exactly what they wanted. Antithetically, the private paying customers will demand what they want and ensure they not only receive what is needed but what is wanted."
PMDs for Kids
Brooke Racicot, PT, PCS, senior director of rehabilitation services at The Children's Institute of Pittsburgh, says what device is best depends on a lot of factors, including the child's cognitive development and physical capability, even his or her vision.
"Age is a major factor. For younger kids, we often recommend a wheelchair with a parental 'kill switch' or with an option to change to manual operation so a parent can control the chair in a crowded location," she says. "The therapist often has an important counseling role, too-parents sometimes see the recommendation of a powered wheelchair as a sign that their child will never be able to walk, and the therapist has to work with them to understand all the benefits."
Racicot has had success putting kids as young as two in powered wheelchairs.
Molly Swenson, DPT, a physical therapist at La Rabida Children's Hospital in Chicago, says 94 percent of the patients she sees are covered under Medicaid, so the choices are limited.
"Our vendor is pretty good about being creative and is a good engineer so he can work with what we are able to get improved and can modify the chairs to make them best for the kids, even without some of the higher-end options," she said. "We deal with kids who a lot of times have postural alignment issues so sometimes having a custom molded seat in the back make it a lot easier to use their arms for power mobility."
Over the years technology has added tremendous abilities to PMDs in making them more efficient. They have the ability to be customized to a greater degree, the materials used are lighter and more efficient, they are easier to repair, offer better braking systems and better front and rear suspensions.
"Some advancements are with control interface technology. One example is the joystick. The ability of the joystick to accommodate for a slight tremor or literally be customized to the patient is paramount in who can use these devices," Weiss said. "Another burgeoning function on PMDs are the LCD interfaces. On some models they actually have in depth software program that can speak and give directions in multiple languages."
With the implementation of the Medicare Competitive Bid Process, Berner has seen manufactures surface who are offering the cheapest power chair because it is low cost to manufacture and they can sell it to wheelchair suppliers cheap. These chairs are poorly made, have few to no features and are not functional.
"If the therapist does not understand what to look for and accepts whatever chair is offered then there is no opportunity to engage patients in choice," she said. "The patient will end up with equipment that does not fit and does not meet their needs."
Sometimes a physical therapist will encounter a PMD that he or she just doesn't like or feels doesn't do what's best for a client.
"We do not like too many limitations to a PMD, such as limited mobility of the device, meaning it cannot be simply transported," Weiss said. "Second, repair ability and poor access to major parts is a big negative. Third, we go with another brand when customer service is lacking."
Remember, it is never one size fits all. It is imperative that a physical therapist understand a patient's big picture completely before moving forward with a powered mobility device. With the right team in place and the patient at the center of the decision, power mobility can change the life of an individual's independence.
Keith Loria is a frequent contributor to ADVANCE. Contact: firstname.lastname@example.org