Rolling For Success! - Sunrise Medicalmarketing.sunrisemedical.com/Education/GoingGreen/... · 2015-03-27 · Rolling For Success! ... Presented by: Angie Kiger, M.Ed., CTRS, ATP

MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Rolling For Success!Design, Materials, and Configurations of an Adult Manual Wheelchair

Presented by:

Angie Kiger, M.Ed., CTRS, ATP

Clinical Education Specialist, Sunrise Medical LLC

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CONFIDENTIAL AND PROPRIETARY

Duplication or Distribution Prohibited

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CEU Information

• All of the STEPS educational presentations have been certified for

Continuing Education Units (CEU) by The MED Group.

• The MED Group has been accredited as an authorized provider by

the International Association for Continuing Education and Training

(IACET).

• This seminar has been awarded 2 contact hours or .2 CEUs by The

MED Group.

• It is the participant’s responsibility to verify CEU validity for state

licensure and/or other entities.

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To Receive CEUs

• In order to be awarded CEUs, the participant must:

– Participate in the entire two hour seminar.

– Complete the entire demographics form, which includes contact

information and the last 4 digits of the participant’s social

security number (SSN).

– Complete the seminar evaluation form.

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Hand-outs

• STEPS is proud to be green!

• You may view and/or print a PDF copy of the hand-outs

for this seminar by visiting:

http://marketing.sunrisemedical.com/Education/GoingGreen/Index.html

http://marketing.sunrisemedical.com/Education/GoingGreen/Index.html

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Objectives

• Be able to identity (3) critical components to the clinical

evaluation for a manual wheelchair

• Identify (3) criteria to consider when prescribing an

independent mobility base.

• Verbalize (3) ways an adjustable rear axle plate can

increase propulsion performance

• Identify (2) reasons why you would prescribe a folding

mobility base, and/or rigid mobility base.

Upon completion of this two hour course attendees will:

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Goals

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Clinical Best Practices

• Are there any related to seating and mobility?

• What would they be?

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How About…

• A thorough hands on mat evaluation must be conducted

– Identify flexible versus fixed postures

– Identify the symptoms versus causes

– Understand functional needs/limitations

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Measurements

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Mat Assessment “Must Have”

• Should be done with the client sitting on a firm surface

– Thighs should be level relative to the hip joint

– Two people assist as needed

– Be sure that feet are supported

• Use a caliper/firm measure stick or tape for accurate

measurements

• Measurements can be done in supine, if sitting is not

attainable

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What About?

• Translate clinical findings into product parameters

• Simulate the proposed solution prior to final prescription

• Client education on equipment use

• Understanding their current funding situation to allow

you to order the best product within their coverage

criteria.

• Future financial planning – plan of care - repairs etc.

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Where Do We Stumble?

• Sometimes shortcuts are taken

with the evaluation

• Sometimes trial is not possible

• Sometimes we battle with the

conflict between therapeutic

perfection – safety and

function.

• Sometimes we do not find out

or understand their funding

situation before the evaluation.

http://images.google.com/url?sa=i&rct=j&q=&source=images&cd=&cad=rja&docid=KAHcWZmlEut-FM&tbnid=y3D198CP0ZgukM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.buzzfeed.com%2Fsamjparker%2Fpeople-falling-over-gifs&ei=mlSvUeyAJ4fMqAHRioDgCg&bvm=bv.47380653,d.aWc&psig=AFQjCNHTHDbzHl6JM1Cw94eDF1hsfc7ObA&ust=1370531302924238

http://images.google.com/url?sa=i&rct=j&q=&source=images&cd=&cad=rja&docid=KAHcWZmlEut-FM&tbnid=y3D198CP0ZgukM:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.buzzfeed.com%2Fsamjparker%2Fpeople-falling-over-gifs&ei=mlSvUeyAJ4fMqAHRioDgCg&bvm=bv.47380653,d.aWc&psig=AFQjCNHTHDbzHl6JM1Cw94eDF1hsfc7ObA&ust=1370531302924238

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Key Assessment Information

Endurance

Cardio-

Pulmonary

StatusSitting

Tolerance

Or Comfort

Acceptance

Access to

Fun

Environmental

Needs:

Access

to Terrain

Access to

Vocation

Function

& Mobility

Seating &

Positioning

Needs

Change

Size/ Weight

Function

Method of

Propulsion:

U/E, L/E or

both

Strength,

ROM

Ortho Status

Tone

Key

Assessment

Information

Reimbursable Non-Reimbursable

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Assessment Determines the Mobility Base

• Independent− UE Propulsion

− LE Propulsion

• Dependent− Positioning

− Transfers

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Independent Manual Wheelchair Categories

Standard Custom

Folding

Custom

Rigid

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Selecting Wheelchair Frame Type

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TRUTH OR MYTH?

• Folding frames have more footrest options?

• Rigid frames are easier to transport due to fewer moving

parts?

• The flex in folding frames may absorb shock?

• Rigid frames allow for more energy transfer to the wheel

during propulsion?

• There is a difference in durability between folding and

rigid frame chairs?

• The rigid frame is lighter weight?

• Maintenance vs. maintenance-free?

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Critical Features

Postural

Balance,

Stability &

Orientation

Sitting

Tolerance

Or Comfort

Acceptance

Access to

Fun

Aesthetics

Arm

Support

Back

Support

Front

Rigging

Caster /

Caster

Housing

Rear

Wheel

Design,

Materials

& Weight

Properly

Adjusted

Manual

Wheelchair

Reimbursable Non-Reimbursable

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Postural Balance & Stability

• Respect precarious balance between

position, stability and function

• Changing seat to back angles

• Footplate height and orientation

• Rear axle position

• Orientation in space all dramatically impact

the seating footprint/contact area

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Postural Balance and Stability

• Postural Balance: keeping one’s center of mass within

the base of support.

– Being stable in sitting to complete ADLs

• Orientation: the ability to maintain appropriate

relationships between body segments and between the

body and the environment for function

(Shumway-Cook, et. al).

• Trunk and pelvic control are key for postural stability!

• Seating system (cushion and back support) impact.

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Postural Balance and Stability

“Squeezing” the Frame:

• To maintain a more erect

posture without loss of stability

during propulsion

• Achieved by tilting the seat

and closing the back angle to

less than 90 degrees

• Requires low back rest to allow

extension over backrest for

postural stability

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Seat Inclination for Postural Support

• Posterior or Anterior Inclination for functional assist

• Environmental Access

• Accommodates longer lower extremities

Posterior Anterior

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Seat Inclination for Postural Support

• Position client so they are sitting “IN” the chair, not

“ON” the chair!!

YES! TRY AGAIN!!

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Product Weight and Set-Up

• Proper combination equals optimal performance!

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Weight Impact on Function

• Choose lightest chair possible.

– A lighter weight wheelchair will reduce the forces needed to propel the chair

• What is the client lifting?

– If weight is concern, think of what components will be removed for transfer

• Read the fine print!

– What is included in the weight?

– Each manufacturers weights can reflect different components

• Remember Configuration.

– Rear wheel placement and components will also have a huge impact on propulsion

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Quality Impact on Function

• Concepts to consider outside of reimbursement

– Optimal Design = less force to propel

• Reduced flex

• Reduced rolling resistance

• Increased durability and tighter tolerances for non-moving

parts as well as ease of motion for moving parts

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Oval Tubing

• The more rigid a chair is the better the performance, the

more efficient the propulsion.

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Oval Tubing

• The tall vertical axis of the Q7’s oval tubing increases its

frame rigidity.

Reduces

Frame Flex

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Biomechanics of Propulsion

Wheelchair Propulsion Phases:

• Push Phase: hands contacting the

push rims

– Anterior deltoid, pectoralis

major, supraspinatus,

infraspinatus, serratus anterior,

biceps brachii

• Recovery Phase: hands released

from the push rims

– Middle and posterior deltoid,

middle trapezius, subscapularis,

supraspinatus, triceps brachii

– Deceleration of the arm after

the push stroke, returning the

arm to the starting position

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Stroke Pattern Types

Arc

Double loop Single Loop

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• Tip of middle finger at hub

• 100-120° of elbow extension at top of push cycle

• Good lateral access

Optimal Rear Wheel Access

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Postural Balance & Stability

• Respect precarious balance between

position, stability and function

• Changing seat to back angles

• Footplate height and orientation

• Rear axle position

• Orientation in space all dramatically impact

the seating footprint/contact area

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Rear Axle, Rear Wheel Size & Position

Also:

• Higher rear axle or lower seat position improves propulsion biomechanics

• Wheels close to user laterally

• No toe-in or toe-out

Goal = adjust rear axle as far forward as possible without compromising

stability of user

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Optimal Rear Wheel Access

• Tip of middle finger at hub

• 100-120° of elbow flexion at top of push cycle

• 70-80% weight over rear wheels

• Good lateral access/camber

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Rear Wheel Position

• Adjust horizontal, vertical, lateral position and camber

using adjustable axle plate or camber tube

Horizontal position affects:

• Wheel access/UE position

• Maneuverability

• COG/stability

Camber affects:

• Wheel access/UE position

• Maneuverability

• Stability

Vertical position affects:

Wheel access/UE position

STFH

Orientation in space

Lateral position affects:

Wheel access/UE position

Overall width

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Horizontal Rear Wheel Position

Wheels Rearward Wheels Forward

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Horizontal Position - Rearward

Positions COG forward

• More weight on casters

• Strength required

• Work for UE muscles

• Overall length/turning radius

• Rearward stability

Affect on wheel access:

• Shoulder in excessive extension to

initiate stroke

• Poor lever arm of force, inefficient

stroke

• Increase risk of UE stress and damage

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Horizontal Position Forward

Positions COG rearward

• Weight on casters

• Strength required

• Work for UEs

• Overall length/turning radius

• Rearward stability

– How much stability does your client

need?

Affect on wheel access:

• Shoulder in more neutral position

• More efficient stroke

• Decrease risk of UE stress and damage

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Horizontal Wheel Position

Wheel Position Forward Wheel Position Rearward

Center of gravity

positioned

More Rearward More Forward

Weight on casters Decreased Increased

Strength required to

propel

Increased Decreased

Wheelbase length /

overall turning radius

Decreased Increased

Rearward stability

(How much is

required?)

Decreased Increased

Wheel access Shoulder position more neutral,

more efficient stroke, decreased

risk of RSI

Shoulder in excessive

extension, poor lever

arm/inefficient stroke, U/E

risk

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Vertical Wheel Position

Move wheels up/down on frame to affect:

• Access to push rim - which affects:– UE position during propulsion

• STFH – which affects:– Access to environment

– Transfers

• Orientation in space – which affects:– Postural stability

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Vertical Position/Rear Wheel Size

Wheels too low/small

• Wheels further from user

• Access to push rim

• Inefficient stroke

• Stress on UE muscles

Wheels too high/large

• Shoulders elevated during propulsion

• Risk of damage to shoulder complex

– Impingement

– Rotator cuff tears

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Vertical Wheel Position - STFH

• SFTH too low:

– Increased pressure on ischials

– Posture compromised

– Inadequate ground clearance

– Environmental access compromised

– Transfers ?

• STFH too high:

– Environmental access compromised

– Transfers affected?

– Posture compromised

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What contributes to poor vertical access?

• Small wheels/casters for low STFHs, but…

– Pediatrics – have small, short UEs

– Elderly– have ROM in UEs• Lets think before using small rear wheels with these

client populations

• Consider axle position to achieve the lower STFH

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Vertical Rear Wheel Position

Seat Inclination

• Rear Seat to Floor Height

is Lower than the Front

Seat to Floor Height

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Seat Inclination

• Minimal tilt /seat inclination can have significant effect

on posture, visual orientation and wheel access

Gravity(Line of vision)

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• To change vertical wheel position:

– Position camber tube above/below frame or move up/down in

axle plate

• Remember impact to caster housing angle…

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Lateral Wheel Position

• Wheels further from frame

– Poor UE position

– Overall width increased

– Improved lateral stability?

– Accommodates more camber

– Accommodates user growth

– Accommodates hardware

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Lateral Wheel Position - Camber

Camber provides:

• Lateral stability

• Efficiency of turns/propulsion

• Wheel access

• Overall width at base 0º Camber

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Optimal Caster – UE Propeller

• 20-30% weight over casters

• Minimize resistance to turning

• Allow optimal LE positioning

• Balance between indoor

maneuverability and outdoor

terrain navigation

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Caster Housing Adjustability

Caster Position and Size

• If caster housing is adjustable, it can be mounted in

forward or rearward position

• Position of caster housing affects:

– Performance, fit, safety and maneuverability

Forward

Rearward

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Caster Housing Angle

• Caster housing must be perpendicular to ground

• Not “squared”, causes:

– Caster float, caster flutter(?)

– Increased effort to turn

– Poor tracking of chair

• Check after changes to:

– Wheel/caster size

– Camber

– Fork/stem bolt length

– Axle plate adjustment ***Assumes chair is configured properly

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Caster Size

Small caster

(i.e. 3”)

Large caster

(i.e. 8”)

Propulsion (flat surfaces) Easier More difficult

Turning Easier More Difficult

“Grab” on uneven

surfaces

Less More

Interference with

footplates

Less More

Front stability

(Depending upon

position)

Less (?) More (?)

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Caster Tire Width

• 5 x 1½" and 6 x 1½" casters

• Beveled bottom creates good compromise

– Middle of tire contacts ground on hard, flat surface

– Full tire contacts ground when in softer surface

Narrow tire Wide tire

Propulsion (hard

surfaces)

Easier More Difficult

Turning Easier More Difficult

Propulsion in soft

surfaces

More difficult Easier

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Caster, Fork and Stem Bolt

• Caster, fork and stem bolt – overall combination affects:

– Front seat height

– Function within the environment

– Turning efficiency

– Performance

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Stem Bolt Selection

Long fork with

std stem bolt

Short fork with

+ 1½" stem bolt

Choose longest stem bolt and shortest fork for optimal

performance at desired seat to floor height

Larger turning radius Shorter turning radius

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Caster Fork Selection

• Length of fork affects:

– Ease of turning

– Size of caster that can be used

Longer fork Shorter fork

Turning radius Most Least

Turning efficiency Least Most

Options for caster size Most Least

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Caster Placement

• Caster distance to the rear

wheel

– If the caster wheel is closer to

the center-of-gravity than the

rear wheel, it bears more weight

and makes turning difficult.

– If the caster wheel is further

away from the center of gravity,

it bears less weight and

becomes easier to turn.

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Front Rigging and Adjustability

• Goal is always to optimize sitting footprint – load the feet

• Optimize turning radius – feet as close to body as

possible

• Respect hamstrings and unique foot angles/positions

• Consider changing needs over time

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Lower Extremity Loading Surfaces

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Angle Adjustable Foot Plate

• This will typically be covered by funding sources if not a

standard item.

• Simply justify its medical need and why a standard fixed

footplate would not work for that specific patient.

Composite Composite Angle

AdjustAluminum Angle Adjust

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Leg Rest Positioning Options

Flared Front Hanger Multi-Position Latch

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Contracture Footrest System

Inside Mount Outside Mount

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Critical Features of Manual W/C Set-Up

• Arm support – Why and When?

• Different types - How do they relate to funding? For

example:

– Swing-Away Tubular arms

– Dual-post/single-post adjustable height arms

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Critical Features of Manual W/C Set-Up

• Arm support – Why and When?

• Different types - How do they relate to funding? For

example:

– Swing-Away Tubular arms

– Dual-post/single-post adjustable height arms

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Backrest Options

Folding adjustable

Non adjustable

Depth Adjustable

Angle Adjustable

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Dynamic Backrest Options

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More Assist Required??

POWER ASSIST SYSTEMS!

1. Individuals with limited upper extremity strength

2. Individuals with compromised respiratory systems

3. Individuals not “ready” for a power mobility device

– Environment reasons

– Psychological reasons

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Quickie SR 45

Quickie TS

Quickie IRIS

Dependent Custom Manual

Non-

Folding

Folding

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Dependent Manual Mobility

• Understanding the benefits of tilt in space, and recline

http://images.google.com/url?sa=i&rct=j&q=recline%20manual%20wheelchair&source=images&cd=&cad=rja&docid=BsL-LYPQ2G6iUM&tbnid=mCkfV734xF__2M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.usmedicalsupplies.com%2Fkarman-ultra-light-reclining-wheelchair.htm&ei=iV7EUaHyB6XWygHR34HwBA&bvm=bv.48175248,bs.1,d.aWc&psig=AFQjCNGigwc9MEnN0m4fy8KfFTvA3pWZ0Q&ust=1371910147799395

http://images.google.com/url?sa=i&rct=j&q=recline%20manual%20wheelchair&source=images&cd=&cad=rja&docid=BsL-LYPQ2G6iUM&tbnid=mCkfV734xF__2M:&ved=0CAUQjRw&url=http%3A%2F%2Fwww.usmedicalsupplies.com%2Fkarman-ultra-light-reclining-wheelchair.htm&ei=iV7EUaHyB6XWygHR34HwBA&bvm=bv.48175248,bs.1,d.aWc&psig=AFQjCNGigwc9MEnN0m4fy8KfFTvA3pWZ0Q&ust=1371910147799395

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Clinical Justifications: Tilt

• Cannot independently change position

– Risk for skin breakdown

– Compromised sitting tolerance

• Needs postural assist against gravity

• Needs specific position or positions to optimize all

functions

• Risk of respiratory complications

• Risk of digestive complications

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Clinical Justifications: Tilt

• Provides for position change

• Minimizes effects of gravity

• Provides increased trunk

stability and head control

• Improves postural alignment

• Improves visual field (fixed

kyphosis)

Tilt vs. Recline - the Pressure Debate

Upright surface area Tilted surface area

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The Road of Documentation

• As we travelled through today’s course, you have seen

how each part ties to the documentation you create and

how it will be used for insurance coverage.

• Documentation plays a critical role within the evaluation

process.

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Critical Questions

• Who is the funding source?

• What is the client’s medical history?

– Diagnosis (primary, secondary, etc.)

– Surgeries (previous and upcoming)

– Medications (past, present, future)

• What equipment has the patient had?

– Not just wheelchairs

– When was it received, why does it no longer meet their needs

(medical - primary)? Who funded the equipment?

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Replacing Equipment

• For many funding sources…

Largest denial cross-country: Same/similar

• Documentation is key!

• Life of equipment - 5 years plus….

• Change of condition - what is needed? This is where

eval’s are crucial.

• No automatics

• So… what do you do? What do you need?

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Common Funding Sources

• State Medicaid Programs

– These vary by state

– Become involved

– Work with your providers

• Private Insurance

• Medicare

– Issues with previous users, now new to Medicare

• How does secondary insurance work?

– Will it matter to you?

• Others…?

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Therapists’ “Keys” in the Area of Funding

• To provide justification that clearly documents that the

client meets the coverage criteria for their funding

source.

• Be sure you are asking for the least amount that is

medically needed for this client to have the

independence that this funding source provides for…

• Key items:

– Independent

– Functional

– Safety

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Manual Wheelchair Set Up

• Make the Right Choices Based on:

– Client’s Goals

– Evaluation Findings

– Research Findings

– Product Knowledge

– Funding Criteria

• CREATE the optimal configuration for:

– Performance, Function and Fit

Hopefully It’s not

Rocket Science ??

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Want More Information??

• “Functioning in a Manual Wheelchair: What are the

Necessary Considerations?” (.4 CEU’s)

• “Adult Manual Mobility: Adult Manual Wheelchair

Technology ” (.7 CEU’s)

• www.sunrisemedicaleducation.com

http://www.sunrisemedicaleducation.com/

MANUAL POWER ADULT PEDIATRICS SEATING GERIATRICS CONTROLS FUNDING

Thank You For Attending!“Always remember that at the end of the day, your client is your number one priority!”

Angie Kiger, Clinical Education Specialist

[email protected]

Documents

Rolling For Success! - Sunrise Medicalmarketing.sunrisemedical.com/Education/GoingGreen/... · 2015-03-27 · Rolling For Success! ... Presented by: Angie Kiger, M.Ed., CTRS, ATP