Power Wheelchair Guide

Purpose of this Guide

Wheeled mobility options can be overwhelming, and it's important to understand when it is clinically appropriate to move to power mobility. This guide is intended to help therapists:  Understanding the qualifications for both manual and power wheelchairs

• Understand the anatomy and functionality of a power wheelchair
• Understand the power wheelchair bases and what base is most appropriate for a client
• Understand the power seat function options and what is most appropriate for a client
• Understand the seating, accessory and drive options that can come on a power wheelchair
• Understand the process of evaluation all the way to delivery of a power wheelchair

Our hope is that this guide will equip therapists to make the most appropriate mobility recommendations for their clients and will increase their confidence and knowledge of power mobility.

This guide is meant to be a comprehensive introduction to power mobility. For advanced learning opportunities, visit the education tab at permobilus.com

This guide is not intended to replace the advice of a medical professional. This guide was created using process and funding guidelines for the United States, including Medicare terminology.

To download the Power Wheelchair Guide as a PDF click here.

Considerations for Determining if Powered Mobility is Appropriate

A variety of factors must be considered when determining if powered mobility is the appropriate solution for your client.

Start with the client and their unique medical, functional, and environmental needs. The following are some considerations to get you started. There are likely other factors that apply to your specific scenario as well. Just remember, the goal is safe and efficient mobility in all necessary environments!

Client presentation

• Client presents with limitations to range of motion of the upper extremity joint
• Client is unable to self-propel a manual wheelchair for a full day, and perform mobility related activities of daily living tasks
• Client presents with limited strength/weakness of the upper extremities
• Caregiver needs assistance to safely manage manual wheelchair up ramps, into van, and for longer distances
• Client has difficulties or is unable to cross the street in a safe amount of time
• Client has postural deformities/postural instability, and these are worsened through strain of propulsion
• Client presents with high risk of upper extremity overuse injury
• Client presents with pain in upper extremities
• Client presents with risk of skin and tissue breakdown, or has a history of skin/tissue breakdown, and would benefit from power seat function(s)
• Client is unable to manage inclines, uneven terrain, thresholds within the home, or changes in flooring
• Client has a history of repetitive strain injury, such as rotator cuff or carpal tunnel syndrome
• Client is unable to transport items within the home, or outside the, home, and propel at the same time
• Client presents with decreased endurance/fatigue
• Client presents with fluctuations in muscle tone/spasticity

Anatomy of a Power Wheelchair

The Process

Understanding Durable Medical Equipment (DME) & Complex Rehabilitation Technology (CRT) Equipment Regarding Power Mobility Equipment

Our guide to Wheeled Mobility 101 goes over the basics of DME and CRT equipment from understanding DME & CRT equipment to determining if your client is an appropriate user for DME or CRT equipment. Check out that information here.

Why would I choose a power wheelchair for my client?

Once you've identified the need for wheeled mobility for your patient, you must consider their need for power mobility. If they are unable to FUNCTIONALLY propel an optimally configured manual wheelchair, then power mobility needs to be considered.

• Remember that "functionally propel" includes the ability to propel in all the desired environments in a safe and efficient way

• Consider a client's prognosis and what their needs will be in the future. For example, a person with newly diagnosed ALS may still be able to perform independent pressure relief, but will need power tilt and recline in the future as the disease progresses

• An individual must have the cognitive ability to drive a power wheelchair

• An individual must express wanting to use a power wheelchair

Power Wheelchair Justification

How do I begin to justify a power wheelchair for my client?

All of the basic criteria for a manual wheelchair apply AND they must meet the basic power wheelchair criteria below:

• • Strength
  • Coordination
  • Pain
  • Range of motion

2. The home has adequate access for maneuvering of the power wheelchair

3.Use of the power wheelchair will significantly improve their ability to perform MRADLs

Standard Power Wheelchair Options

Click on each standard power wheelchair option below to learn more

DME Power Operated Vehicle (POV)/Scooter

DME Group 1

DME Group 2

CRT Group 3

CRT Group 4

CRT Group 5

Power Mobility Equipment

DME Power Mobility Devices 

As indicated in the chart of Standard power wheelchair options, DME power mobility devices usually have limited adjustability. The following DME products meet all of the basic power wheelchair criteria while having their own qualifying criteria. Click on each category to learn more about the qualifying criteria and limitation of each DME power mobility device. 

DME Power Operated Vehicle (POV)/Scooter

DME Group 1

DME Group 2

CRT Power Mobility Devices 

As indicated in the chart of Standard power wheelchair options, CRT power mobility devices are the most customizable power mobility devices. The following CRT products meet all of the basic power wheelchair criteria while having their own qualifying criteria. Click on each category to learn more about the qualifying criteria and limitation of each CRT power mobility device. 

CRT Group 3

CRT Group 4

CRT Group 5

Drive Wheel Placement

What is the significance of the drive wheel placement?

The drive wheel on a power wheelchair is the larger wheel if you are looking at the wheelchair. 

The location of this drive wheel can have a large impact on how the power wheelchair drives and maneuvers in different environments.

When determining drive wheel placement always consider the primary environments the wheelchair will be used in as well as what the client has used previously, if not their first wheelchair.

Benefits and Considerations of Drive Wheel Placement:

Front Wheel Drive

Mid Wheel Drive

Rear Wheel Drive

Techniques for Optimizing Power Mobility

How does drive wheel placement affect maneuverability in the home?

For indoor use, consider the turn radius/maneuverability. This is very important to many users as it will dictate the ease of entry into rooms and how close they can get to surfaces in order to perform an MRADL.

Base length, including the footrests plus the drive wheel position, will determine the turning radius. Keep in mind that a turning radius does not equate to functional maneuverability. 

Taking a Closer Look at Front Wheel Drive

People have a tendency to steer clear of front wheel drive because:

• It doesn’t have as small of a turning radius as mid-wheel drive
• It is harder to learn to drive

Both of those statements may be true depending on the person (some people feel FWD is easier to learn), BUT NOT A REASON TO STAY AWAY!

Front wheel drive may be less intuitive to learn how to drive versus mid-wheel drive, but with a little practice and a few key tips, many users have success in learning to drive a FWD base.

Tips for teaching front wheel drive

The two key points when teaching to drive a front-wheel drive wheelchair is:

1. Hug the corner. When going through a doorway the end-user will want to “hug” the corner or keep a tight turn.

2. Turn towards the problem. For example, when positioned adjacent to a wall/barrier, turn toward the wall/barrier, then slightly reverse to allow the rear casters clearance for turning in the desired direction. This might sound complicated, but if you remember to turn into the problem you will easily maneuver away from the problem.

Understanding Power Seat Functions

Power seat functions are simply the different positions that a power wheelchair can achieve by using a joystick, alternative drive control, external switch, or switch box. Click on each power seat function below to learn specifics. 

Power Tilt

Power tilt can refer to anterior tilt where the seat tilt anteriorly "without changing the seat-to-back angle" (Waugh & Crane, 2013, p. 48) or to posterior tilt where the seat tilts "posteriorly without changing the seat-to-back support angle or seat to lower leg support angle" (Waugh & Crane, 2013, p. 48)

Power Recline

Power recline "allows the back support to pivot posteriorly, increasing the seat to back support angle" (Waugh & Crane, 2013, p. 48)

Power Elevating and Articulating Lower Leg Support

Allow clients to change the seat to lower leg support angle in order to flex or extend the knee.

Some legrests articulate, that is, lengthen while extending the knee.

Power Seat Elevation

Power seat elevation "allows raising and lowering the whole seating system, changing the seat to floor height without altering the angular orientation of the seating supports" (Waugh & Crane, 2014, p. 48)

Power Standing

Power standing "is capable of raising the occupant from a seated to a standing position by changing the orientation in space of all the primary seating support surfaces" (Waugh & Crane, 2013, p. 48)

Power Seat Function Combinations

Power seat functions can always be combined. The available power seating options, however, are dependent to some extent on the type of power wheelchair base selected. Not all power wheelchairs can accommodate all power seat functions or the amount of the power seat function required for medical and/or functional needs.

Drive Control Basics

There are two different style of drive control: proportional drive control and non-proportional drive control. 

Proportional Drive Control

Proportional drive control means that the driving action (speed, direction) is relative to the amount of deflection of the joystick away from neutral and the direction of that deflection. A proportional drive control can be a standard joystick, or it can be a variety of other alternative drive controls that have similar functionality.

When considering a proportional drive control, you must consider the client’s movement and strength as it relates to the throw and force required of the drive control.

Throw: The amount of deflection or travel (from neutral) it takes to reach maximum speed (typically measured in millimeters)

Force: Force required to move the joystick from neutral (typically measured in grams)

Non-Proportional Drive Control

When an individual does not have the strength, range of motion, and/or coordination to operate a proportional drive control, a non-proportional input device may be considered.

Also known as switched or digital drive control, these devices are either “on” or “off” and typically allow 4 to 8 discreet directions of movement.

For example, the wheelchair may be controlled by four individual switches that the user hits to activate the wheelchair – one for each direction of forward, reverse, left, and right.

A six or eight direction control might have a command or switch for each of the following directions.

Mechanics of the PWC

The are key factors when evaluating power base performance. Power wheelchair bases should be able to help a user navigate a variety of spaces and terrain safely and efficiently. Suspension, torque, and tracking all play a key factor in the wheelchair's ability to do so with minimal jarring to the user.

Suspension

"Mechanism of a device that is intended to reduce vibration" (Waugh & Crane, 2013, p. 32)

Torque

Torque is the twisting/turning force that causes rotation around an axis. In power wheelchairs this is a function of appropriate gearing of the gear box to assure the powerbase can navigate obstacles effectively.

Tracking Technology

“Motor technology that helps a power wheelchair to travel in a true forward direction on various terrains” (Waugh & Crane, 2013, p. 43).In short, tracking technology helps the wheelchair stay on the desired route by compensating for environmental aspects that would otherwise cause the chair to veer.

Evaluation & Measurement Guide

Our beginner's guide to fundamentals of wheeled mobility, Wheeled Mobility 101, goes over the therapy evaluation along with how to measure for properly fitting wheelchair components. Click on the links below to learn more about each topic. 

The Therapy Evaluation: The Pieces required to justify wheeled mobility and seating equipment

How to Measure for Properly Fitting Wheelchair Components

Key Measurements for Power Mobility

Can I add CRT Seating components to a power wheelchair base?

Some Group 2 bases will allow this, but it is most common in Group 3 and above.

CRT seating components:

Funding for Power Mobility Equipment

Is funding a power wheelchair dependent on diagnosis?

NO. Funding is highly determined by the functional and medical needs of a client. Although Medicare states “the beneficiary’s mobility limitations is due to a neurological condition, myopathy or congenital skeletal deformity”, a clear picture of functional and medical reasons can justify the need for power mobility.

What does best practice look like from a funding standpoint?

There is no cookie cutter solution for funding powered mobility devices. Every individual is unique and has specific needs and therefore best practice is to always put the client first!

Often a “top down” model is used with the funding source (i.e.,  insurance) at the top deciding what is and isn’t paid for. Unfortunately, at times, this leaves the consumer as the last to be considered in the equation.

For example, under Medicare, a seat elevator is considered a luxury item and not deemed medically necessary even though this power seat function could mean the difference between independence or the need for assistance with a transfer.

This approach has a trickle-down effect on client access and product innovation. If a function or item improves independence, it should be medically necessary and paid for by the funding source.

Are there any resources to help if I'm new to justification for power mobility?

Yes! Permobil offers an on-line LMN Generator. 

For free access to template justification language, sign up at  www.permobillmn.com. Templates are a great starting point, but your justification must always be customized to the individual client and their specific medical and functional needs.

Common Funding Misconceptions

Myth 1: A Group 2 power mobility base meets the client's needs the same as a Group 3 power mobility base.

For client’s with complex needs, a Group 2 base may not provide the necessary features resulting in sub-optimal outcomes. Specifically:

• A Group 2 base does not accommodate multiple powered seat functions that have the range of movement that a Group 3 base does. This could put your client at increased risk for pressure injury or loss of functional ability within the power wheelchair.
• The suspension requirements are less in a Group 2 wheelchair. For individuals who are in a wheelchair all day, every day, this can impact sitting tolerance, positioning, spasticity, and increase exposure to whole body vibration.
• The battery range requirements are less in a Group 2 wheelchair. Again, for individuals who are a wheelchair all day, every day, often longer battery range is required to get them through their day.

Myth 2: Group 4 power mobility bases are for outdoor use only, and therefore not covered by insurance.

While a Group 4 power mobility base is considered a non-covered item under Medicare, some state Medicaid and private insurances will cover a Group 4 base with the appropriate justification. Remember, recommend what your client needs medically and functionally!

In addition, Group 4 power mobility bases are not just for outdoor use. You may consider a Group 4 base for other reasons such as:

• The need for additional range in seating angles prior to speed reductions or drive inhibits.
• The desire to add a power standing seat function to the chair.
• Client has high sensitivity to impact or significant spasticity triggered by impact and the improved suspension of the Group 4 base addresses these issues (thresholds, ramp getting into home, driveway, etc.).

Myth 3: Power seat elevation is not covered by insurance.

Power seat elevation is covered by some state Medicaid programs and private insurances. Use of vocational rehabilitation funds may be a consideration as well if the person is attending school or work, and the seat elevator helps them in those roles.

Common Funding Questions

The following five questions are frequently asked in the industry. Click on each question below to find out the answer.

What if I'm being told my client doesn't qualify for a power wheelchair?

How does my client qualify for tilt and recline?

How does my client qualify for elevating legrests?

I've heard the standing power seat function is never covered by insurance, is that true?

Can my client pay for components out of pocket if they choose to do so?

Special Considerations

There are a few topics in power mobility that are not easily classified into a category. In this section we explore these topics of special consideration.

Pediatrics in Power

Why would I put a child in a power mobility device?

Children develop through movement.

Play is how babies/toddlers interact with their environment and is a vital activity in all aspects of development. (Rosen, L et al 2017)

Children with cognitive and/or physical limitations respond to play as well, and when provided with the ability to move, can even initiate play with others. Early power mobility can provide a child the opportunity to play and interact rather than simply being an observer.

Who can benefit from power mobility in the pediatric population?

• Children who will never walk.
• Children with inefficient manual mobility.
• Children who lose the ability to walk or to walk efficiently.
• Children who need mobility assistance in early childhood. (Rosen, L et al 2017)

How young can a child be to trial power mobility?

Just like babies/toddlers need to learn the skills of rolling over, crawling, and walking, young children need to learn the skills for power mobility. Children as young as 14-17 months old have shown the ability to learn power mobility skills when provided with frequent opportunities to practice. (Casey, et al 2013)

Would a toddler spend the whole day in a power mobility device?

No. At this young age, a PMD is used as a therapeutic tool for short periods while supervised. It creates opportunities for toddlers to develop strength, exploratory behaviors, emotional expression, and postural control. (Plummer et al., 2020)

Power Assist

A power assist is the use of technology to assist with the "push" phase of independent manual wheelchair propulsion. Learn more about power assist devices in our manual wheelchair guide. 

When should I consider power assist?

Be proactive instead of reactive! Power assist can prevent upper extremity overuse injury and promote increased independence and safety.

I can’t provide power assist because a Group 2 power wheelchair is so much cheaper. Is this true?

Insurance companies typically pay for the least costly, medically appropriate alternative. Here are some considerations to determine when power assist may be most medically appropriate:

• A manual wheelchair user who has their entire home environment and mode of transportation adapted to accommodate a manual wheelchair.
• A manual wheelchair user who has complex postural needs that are accommodated for by an individualized seat cushion, back support, and postural supports that can not be achieved on a Group 2 power wheelchair.

Alternative Drive Control Options

What is an alternative drive control?

It’s using a different way to drive the wheelchair and access your power seat functions. Joysticks are the standard, but sometimes clients don’t have the upper extremity control, endurance, or coordination to use a joystick.

What if my client can't use a standard joystick?

Address the following with a standard joystick before changing to an alternative drive control:

• Positioning of the individual
• Mounting/placement of the joystick
• Alternative joystick knobs (shape, texture, height)
• Programming adjustments (e.g., throw, tremor dampening, deadband, etc.)
• Must consider not only joystick access, but secondary function access such as mode, power seat functions, power on/off
• There are many other options available depending on the movement and strength of your client! Keep in mind that as client ability decreases, technology needs increase.

What do I need to consider when selecting an alternative drive control?

Once you've assessed all the considerations on page x with a standard joystick an alternative drive control may be required:

• Maximize the client’s positioning and stability needs before beginning the drive control evaluation.
• Identify where the client has movement and where the movement is most consistent – start there.
• Evaluate how much movement the client has. Ask how much range of motion is required to effectively operate the alternative drive control being considered. Do different positions of the drive control elicit more or less access and consistency?
• Evaluate how much strength the client has. Ask how much strength is required to deflect the chosen proportional input device and ask how much strength is required to activate the switch/non-proportional input device.
• Consider access to seat functions, other modes such as Bluetooth, as well as power on/off.
• Will the client fatigue over the course of the day? Does the client have enough endurance for the chosen drive control?
• How does the client shift throughout the day or with power seat function use? Will this impact access to drive control?
• Consider the cognitive demands of the drive control and the client’s cognitive status.
• Some clients with fatigue can use a standard joystick part of the day and require an alternative drive control for part of the day.
• If your client has a progressive disorder, consider potential future alternative drive control needs/options and discuss with the equipment supplier. Depending on how quickly your client is progressing, sometimes alternative drive controls are ordered before they are needed.

Types of alternative drive control

Click on the different types of alternative drive controls to learn more about each

Head Array

Uses head movement to activate proximity or mechanical switches built into pads. Some newer models also have a proportional component.

Sip and Puff

Sip & puff is a pneumatic switch that uses varying air pressure from the person's mouth via sips in or puffs out, to control the wheelchair.

Switch Arrays & Multiple-Switch Control

A switch array is a series of two or four switches (proximity or fiber optic), typically mounted in a tray, used to operate the power wheelchair. Multiple switches can also be set-up wherever needed based on the user’s available movement. When using multiple switches, a combination of mechanical, proximity, or fiber optic switches may be used based on the available movement and strength at each switch site.

Single Switch Scanning

Single switch scanning allows for operation of the power wheelchair with a single switch. The user display (or separate box mounted to chair) gives a visual cue of direction (example pictured below), typically through an arrow or light that scans 4 to 8 discreet directions. The user activates the switch once the arrow or light reaches the desired direction. The switch may be programmed as momentary or latched. 

Eye Gaze

Eye gaze allows for power wheelchair operation through use of eye movement via an eye tracking device and tablet computer mounted on the wheelchair.

Wheelchair Technology & Connectivity

Wheelchairs have advanced with technology in recent years, and these features can help your clients in many ways.

Bluetooth: Advanced electronics allow end users to connect to their smart devices via Bluetooth technology. This enables them to use the input device to both drive their wheelchair and control their paired phone or tablet.

Apps: Some manufacturers have developed wheelchairs that communicate with apps on their smart devices. These can provide end users with:

• power seat function angles and activity tracking
• reminders to help effectively manage pressure relief protocols
• real-time battery status updates
• integrated maps with accessibility information
• wheelchair data for service diagnostics

Remote connectivity: Service technicians can remotely access wheelchair data to help diagnose potential issues, resolve simple fault codes, and better prepare for service visits.

Conclusion

It's important to keep the following in mind as you work through the evaluation, justification, and delivery process. Think about both short and long-term needs, and then do the best you can for your client! Evaluate each individual to identify their needs and goals medically, posturally, functionally, and environmentally.

• Maximizing client comfort, minimizing pain, correcting deformities when possible, preventing further deformity, preventing pressure injury, maximizing safety and functional independence, assuring independence in all necessary environments.

• Identify seating and mobility equipment that will meet these needs. Connect clients needs to recommended equipment solutions in documentation.

• Remember that power wheelchairs with power seat functions can provide important health, function and participation benefits - think big picture when evaluating how power seat functions may improve outcomes!

• Power assist devices can be a great solution if a manual wheelchair base is most appropriate given the clients environmental and functional needs.

• A client-centered evaluation and delivery, including set-up and training on the device, are key to success in achieving best client outcomes.

You are going to need to advocate for your patient now in order to get them the proper equipment that can address their needs over time.

Click here to download the Power Wheelchair Guide as a PDF.

Click here to view the glossary for the guide.

Click here to view the list of references.