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Seating and wheeled mobility evaluation

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Selection of a wheelchair, as well as a client’s positioning in the chair, are influenced by many factors. These include physical status (abnormal tone, available range of motion, muscle strength/imbalance, orthopedic deformities and balance), functional status, environmental issues, transportation status and lifestyle. A thorough evaluation can provide information about each pertinent area. Each client will have different goals and priorities and determining the relative importance of these goals will help to determine the features of the seating and mobility system that are most appropriate and important to that particular client. Often there are conflicting goals and trade-offs, which make a thorough seating evaluation process vital to achieving optimal outcomes. Wheelchair selection is best performed with the help of a client-centered team. The team should include, but need not be limited to, the client, family and/or primary caregivers, physician, primary physical and/or occupational therapist, assistive technology specialist (specializing in seating and wheeled mobility), case manager and rehabilitation technology supplier (RTS). Not all of these people need to be present at the time the seating and mobility system is selected, but their input can be extremely beneficial and, at times, essential to a successful outcome. Input from additional experts may be needed, such as adaptive driving and van modification specialists to address transportation issues. Generally, individuals who are receiving their first wheelchairs rely more heavily on the input of multiple team members; those seeking replacement wheelchairs often have a very good sense of what has and will best suit their needs.

A comprehensive evaluation consists of multiple components: the interview, physical/postural assessment, seating simulation, equipment trial and prescription. Each of these can be further broken down into multiple sub-components.


Contents

Interview

During the interview, basic client data is collected (date of birth, height and weight) along with medical history, equipment history, environment(s) in which the wheelchair will be used, ADL/transfer status, method of transportation, driving status and funding status. Because third-party payers often have timelines for equipment replacement (e.g. every five years), it is important that the information collected reflects changes that are anticipated over that timeframe. For example, it should be noted if the diagnosis is progressive, if there is a trend for weight loss/ gain or anticipated growth (for children), any planned surgeries which may effect seating/mobility needs, any plans to change housing or mode of transportation or plans to start school or a new job. Listing and prioritization of client goals is also crucial to the interview process. In the case where a client may require assistance to use the equipment it is important to also note the input of the caregiver. The caregiver must be comfortable with, and capable of, the supportive role required for successful use of the equipment. The evaluation is the time to work through any issues of incongruence, versus after the equipment arrives. If the client is seeking a replacement wheelchair, providing input on past equipment success and failures helps to assure that positive features will be re-sought, and equipment feature failures will not be repeated. In addition, any other equipment, which will be used in conjunction with the new wheelchair/seating, must be reviewed to assure it will interface effectively.


Physical/Postural Assessment (Mat Eval)

The primary focus of the physical assessment is to determine if there are any barriers to achieving a functional, comfortable, upright seated posture. The postural assessment is done both with the client in supine and in sitting (noting the effects of gravity). Key areas to address in supine/side-lying include: skin integrity, spine/pelvis mobility, presence of orthopedic deformities and whether each is flexible or fixed, presence of abnormal tone, adequate joint range of motion (ROM) for the seated posture and adequate ROM and strength for the mode of propulsion or drive control. Key areas to address in sitting include balance and the presence of asymmetries/orthopedic deformities, including how these may differ in sitting under the influence of gravity and the amount of force required to correct/reduce the deformity, if flexible. If abnormal tone is noted in supine, this should also be re-assessed in sitting, as there are often positional differences. Anatomical dimensions (which are used to choose wheelchair and seating product dimensions) should also be taken in sitting, but it is crucial that the client is supported in the posture which will be assumed in the wheelchair.


Seating Simulation

The seating simulation can be done in an actual simulator or using a highly adjustable wheelchair. The physical assessment findings guide the determination of what product features are needed for the seating system and wheelchair. Seating and postural needs should be determined first, before moving onto the mobility system. It is helpful to go through this intermediate step of listing the needed features of the seating system, which the RTS can then use to identify specific commercial options which best meet the client’s needs, most cost-effectively. Especially in the case of a client with complex postural needs, use of a seating simulator helps to cement the product feature list, including the desired location of postural support components. Seating simulators are highly adjustable with respect to the seat and back surfaces (including tilt and recline) as well as the postural support components. They are used to verify how to best set up a seating system to provide the necessary postural support with respect to optimizing balance, comfort, visual orientation, correcting flexible orthopedic deformity or accommodating fixed deformity. High functioning clients, who do not have significant postural compromise, are not as likely to need to go through the step of using an actual seating simulator. Their postural needs are best determined using a properly configured wheelchair, so that postural support can be assessed in conjunction with effective propulsion.


Equipment Trial

Once the postural needs are determined via simulation, the next step is equipment trial, wherein the seating components are married to the mobility base, whether a manual or power wheelchair. It is preferable for the team, lead by the RTS, to provide multiple options for trial and comparison, which contributes significantly to a good match of client’s needs to the technology, as well as client satisfaction of the recommended equipment. Ordering equipment without benefit of trial is strongly discouraged. The wheelchair and seating are set up using the simulation findings. Naturally, the types and number of different postural components are unique to each individual. Also, remember that generally there are trade-offs: for example, using more postural supports may mean less freedom of movement. A wheelchair recommendation is usually a delicate balance of the two. One should be mindful of using a minimalist approach so that the equipment does not overtake the individual. Additionally, in the case of manual wheelchairs, minimizing accessories can help keep the system weight to a minimum, which contributes to efficient propulsion and aids in prevention of shoulder injury. Optimally, whenever the client is a first time user, or a significantly different type of wheelchair is being considered (e.g. changing from manual to power), the equipment should be tried in the client’s environment with regard to accessibility. In some cases, this is a requirement of the third-party funding source.


Prescription

Once the wheelchair and seating are selected via the trial process, the specific equipment recommendation or prescription is completed by the primary team (at minimum the client, therapist/AT specialist and the RTS). Each manufacturer provides order forms, which are used by the team to select specific dimension, configuration and component options. The therapist/AT specialist is responsible for writing a letter of medical justification, which supports the recommendation and must be approved by the physician. Occasionally, the letter is written by the physician, for example a physiatrist or specialist in rehabilitation medicine. This is submitted by the RTS to the funding source, together with the quote and any additional supportive documentation. After funding approval is obtained, which can vary from days to months, the equipment is ordered by the RTS.


Delivery

Delivery of the equipment should occur with the primary team gathered to assure the best quality outcome. Each team member has a unique and essential role. The RTS verifies that the equipment was correctly ordered (should be done well ahead of delivery appointment) and configured, the therapist assures that the set up is optimal to meet the client’s needs (especially if there have been any changes in condition since the evaluation) and the client confirms that the equipment order and set-up. The RTS reviews maintenance and operational features with the client; the therapist reviews clinical items such as seating component set-up, confirms wheelchair configuration with respect to wheelchair skills/transfers and reviews driving specifics in the case of power wheelchairs. The client should not leave the delivery appointment without knowing how to safely operate and oversee the maintenance of the equipment. Before the conclusion of the delivery appointment, it may be determined that additional training sessions are needed to optimize use of the equipment. The technology team should be available for follow-up to address any concerns that may arise after the client has had a chance to use the equipment. Examples of follow-up needs include: reprogramming of power wheelchair electronics to optimize driving; seating system set-up may need to be re-addressed to optimize balance, postural stability or skin integrity; rear-axle position may need to be fine-tuned to optimize propulsion or balance point for wheelies. Lastly, the RTS must provide maintenance/repair services as needed throughout the life of the equipment.


|- Author: Kim Davis |- Affiliation: CATEA, Georgia Tech |- Email Address: kim_davis@shepherd.org |-