Wheeled Mobility 101

Purpose of this Guide

This guide is intended to demystify the provision of wheelchair seating & positioning for healthcare professionals. The aim is to assist healthcare professionals in achieving optimal individualized wheelchair seating to meet the goals for each client by:

• Understanding the qualification for both manual & power wheelchairs
• Identifying the abnormal postures and understanding how ill-fitting wheelchair components lead to abnormal postures and pressure injuries
• Understanding how to select the proper seating components
• Identifying the key components to completing a successful wheelchair evaluation
• Translate the need for a mobility device to the most appropriate wheelchair model and options
• Understand how to effectively document and justify the equipment chosen and meet the necessary requirements
• Understand what the components of an ultra-lightweight manual wheelchair are and how to appropriately measure for optimal configuration

This guide was created using process and funding guidelines for the United States including Medicare coding terminology. Therefore, some terms such as K0005 and Ultra Lightweight Manual Wheelchair, are considered to be interchangeable throughout. This guide is meant to be a comprehensive introduction to manual mobility. For advanced learning opportunities, visit the education tab at permobilus.com

Challenges to providing wheelchair seating & positioning services/the appropriate wheelchair

Identifying the Need

How do I know that my patient needs wheeled mobility?

Consider your patient’s quality of life. Document any of the indicators below to justify the need.

1. Patient is non-ambulatory

2. Demonstrates decreased safety with ambulation or is at risk for falls within the home. Ask about history of falls; perform an objective balance assessment, e.g. BERG Balance Scale (BBS), Dynamic Gait Index (DGI), Timed Up and Go (TUG)

3. Requires assistance for ambulation within the home and wheeled mobility would allow independence

4. Requires increased time for ambulation within the home. Perform a gait speed test; think about performing ADLs in a reasonable amount of time

5. Unable to consistently ambulate throughout the day in the home, which affects their ADLs. Look at a 24-hour period

6. Their current wheelchair is in disrepair or not meeting their needs for mobility or postural support.

Here are scenarios where wheeled mobility could significantly increase a person’s quality of life:

• They can ambulate but are at high risk of falls
• They have frequent urge incontinence because they are unable to get to the restroom on time
• Their O2 saturations drop below or heart rate increases above a safe range with ambulation
• Their day consists of sitting in a recliner and transferring to a bedside commode as needed
• Nature of their diagnosis, over-fatigue is contra-indicated, and a WC is required in order to avoid exacerbation of symptoms.

The Team

Is it only up to the physician and/or therapist to decide on a patient's equipment?

No! The most important part of successfully providing appropriate equipment is understanding that it's a team effort.

Meet the team: Each member plays a role in the selection and attainment of proper equipment

It is critical for health care professionals to develop a relationship with a reputable dealer who employs an ATP.

The Process of Getting Seating Equipment

Where do we start?

First, let’s look at the big picture of how to get wheelchair seating & positioning equipment.

Understanding DME & CRT Equipment

Let's start with the basics: is all wheeled mobility and seating equipment classified the same?

NO! When it comes to seating and wheeled mobility, products are divided into two groups: Durable Medical Equipment (DME) and Complex Rehabilitation Technology (CRT). Patients will qualify for certain equipment based on the severity or complexity of their condition. Most products are covered based on diagnosis, and some are covered because lesser products have been tried and were found to be inappropriate.

"CRT products include medically necessary and individually configured manual and power wheelchairs, seating and positioning systems, and other adaptive equipment such as standing devices and gait trainers. This specialized equipment requires evaluation, configuration, fitting, adjustment, or programming to meet the individual’s medical needs and maximize function and independence.

CRT products must be provided by individuals who are certified, registered or otherwise credentialed by recognized organizations in the field of CRT and who are employed by a business specifically accredited by a CMS deemed accreditation organization to provide CRT." 

“National Coalition for Assistive and Rehab Technology.” NCART, 2019, www.ncart.us/.

If you provide a DME wheelchair, are you limited to DME cushions and back supports?

No! You can provide ANY cushion and/or back support with DME mobility devices. The choice should depend on the patient's need for seating and positioning. Even individuals with limited mobility may require postural support, stability, skin protection, and increased comfort.

The Therapy Evaluation

The pieces required to justify wheeled mobility and seating equipment

Addressing equipment issues can sometimes result in upright posture. However, in many other cases, there are also physical limitations that prevent the client from maintaining or even achieving this “ideal" posture. In these cases, you need to identify the “client-related” issue(s) in order to choose the best seating solutions. This requires a seating evaluation.

How is a seating evaluation different than a typical OT/PT evaluation?

Don’t let the term “Seating Evaluation” scare you!! In addition to your typical evaluation, you MUST assess and document the following:

Home Environment

Measurements of doorways, table, height, bed height, stairs, etc

Transportation

Document what kind of car they drive and/or ride in

Mobility Skills

How do they currently get around to perform their daily tasks? Be descriptive (efficiency, ability)

Current Seating/Mobility

Describe ALL current equipment and the condition of each

Measurements

Complete the 8 key patient measurements to ensure proper fitting equipment

Equipment Trials

Explain why a lesser product will not work and how the selected product increases independence in the home

• Understand that you are doing your typical OT/PT evaluation and adding a few components to your documentation
• Assess limitations in ROM, strength, balance, and endurance and how they affect posture in the wheelchair
• Choose an adjustable wheelchair model that provides an individualized fit.
• Consider seat cushions, back supports, head supports, and other accessories to address the patient’s physical limitations
• Schedule a visit with your trusted ATP/Dealer to trial equipment with your patient

How to Measure for Properly Fitting Wheelchair Components

Measuring Tips

1. All measurements should be taken while sitting on a firm, flat surface in the posture the therapist is trying to accomplish for the patient.

2. Measure using a hard measuring tape, not one that can bend and wrap around the patient’s body. This will lead to measurement errors, adding circumference or length.

3. All measurements should be taken straight across the body.

4. Use a measurement form to remind you of the measurements needed and to record them properly.

What are the measurements that I need to take?

You will need to perform the following required measurements when choosing the best fitting equipment. Click here to download an easy-to-use measurement form to document your findings in the field.

Specific Measurements

Measuring Seat Dimensions

Remember to have patient sitting on a flat, firm surface for accurate measurements

How to measure SEAT WIDTH (C): Measure from widest point to widest point of the hips, including all residual tissue

How to measure SEAT DEPTH (K): Measure from the buttocks, including any excess tissue, across the femur to the popliteal fossa
Then subtract 2"

Measuring Back Support Dimensions

How to measure SHOULDER WIDTH (A): Measure from humeral head to humeral head, incorporating excess tissue

How to measure CHEST WIDTH (B): Measure from axilla to axilla. This measurement helps determine back support width.

How to measure HEIGHT (G or H): Measure the patient in the position you are striving to achieve

* Measure both sides L & R in case of scoliosis and/or a pelvic obliquity
* An average back support height for a self propeller is 16” tall, unless you have an active client who requires more freedom of movement and is more independent.

Measuring STFH/Lower Leg Length

How to measure LOWER LEG LENGTH (L): Measure from the top of the patient's seat (top of cushion if applicable) to the floor

Measure with feet on floor (with shoes that they normally wear or barefoot if they do not normally wear shoes) and measure bottom of foot/shoe to popliteal fossa

* There must be a 2” clearance between foot plate and floor to clear thresholds.
* If providing the patient with a new cushion, remember to consider the thickness of the desired cushion and adjust STFH accordingly.

Measuring Arm Rest Dimensions

How to measure ARM HEIGHT (I): Seat your patient with shoulder in neutral and elbow bent at his or her side to 90°

Measure from top of seat to under forearm/elbow

How to measure ARM LENGTH (J): If patient needs a specialized arm length, measure from end of elbow to where the therapist wants the desired replacement arm support to end

* Measure both side in case of pelvic obliquity/scoliosis. This will justify the need for a model of wheelchair with adjustable height arm rests.

Head Support Positioning

There is no miracle formula for fitting a patient for a proper head support

• The rest of the body must be in the best alignment possible before trying to fit for a head support
• Remember that head position changes constantly with the slightest body movement
• Aim to position the pad in the suboccipital area 
• Choose a head support with lateral, anterior/posterior, height, and angle adjustability

* Head support hardware that has offset capabilities accommodates patients with head position out of midline.