Vik: Hi everybody! I primarily work in New York with a veteran population, specifically within the St. Albans, Brooklyn, and Manhattan VA facilities, St. Albans is a long term care facility, and the other two are acute care hospitals. I have had the grateful opportunity to work with veterans, especially within the area of seating mobility. I would love to share that with you today.
Older people are considered to be the fastest growing population in the world. As people age, there are many affected with physical illnesses and neurological conditions that are associated with deterioration in physical ability, function, and well-being. With advancing age, we have an array of co-morbidities and issues that we have to address. We have to take these all into consideration during seating and mobility assessments and interventions. From the U.S. Census Bureau in 2010, more than 3.6 million people in the United States depend upon a wheeled mobility device, whether that be a wheelchair, a rollator, a walker, or a scooter to perform ADLs and IADLs. There is a large dependency on wheeled mobility devices.
Seating and wheeled mobility services are provided by OTs, as well as PTs, including specific positioning equipment, mobility devices, durable medical equipment (DME), and complex rehabilitation technology, or CRT. These are all used to optimize clients' environmental access and their ability to perform daily occupations. Seating systems or equipments are designed to meet individuals' needs for postural support and alignment, skin integrity, function and safety, which are two big ones. Research shows that their is a positive impact of equipment, such as wheelchairs, on the quality of life for individuals with mobility issues.
Long Term Care Facility
What is a long term care facility? When I started, there were a lot of names thrown out there, but I was not quite sure exactly what defined a long term care facility. Nursing homes, skilled nursing facilities, and assisted living facilities are collectively known as long term care facilities. They provide a variety of services, both medical and personal, to people who are unable to manage independently in the community (Center for Disease Control and Prevention). Long term care facilities have a variety of services designed to meet a person's health or personal care needs during a short or long period of time. This is another bias I had in the beginning, I was not quite sure if most individuals in a long term care facility were short-term or long-term, but technically they can be both. These services help people live as independently and safely as possible while they can no longer perform everyday activities on their own, according to the NIH. They provide the most basic level of care and then some. These levels of care include ADLs as well as IADL assistance. More specifically, assistance with bathing, dressing, toileting, and transferring. If an individual has quite a number of falls or has a history of falls, transferring does come into play as well. They also provide caring for incontinence and dietary needs.
There are many skilled services rendered in a long term care facility.
- Mental health
- Physiatrist, etc….
Most commonly skilled services include medicine, dietary, nursing, rehabilitation (PT, OT, and speech). Religious services can be provided. Respiratory intervention is quite common. Specialized units might provide palliative or hospice care. Additionally, nutrition, podiatry, and other services are offered.
Rehab services rendered in a long term care facility are basic ADLs, toileting, bathing, transfers, ambulation, and eating. Seating and mobility services are also rendered in long term care.
Seating and Mobility Services
Medicare Part B or medical insurance covers power-operated equipment such as scooters and power wheelchairs, manual wheelchairs, and durable medical equipment (DME) that your doctor prescribes for you in your home. In order to receive one, you must have a face-to-face examination and a written prescription or script from a doctor or other treating provider before Medicare helps pay for a power wheelchair. Most power wheelchairs and manual wheelchairs are covered only when they are medically necessary. This is where you come into play as a clinician. How do you as a clinician determine or justify if it is medically necessary? You have to use your clinical knowledge on medical conditions and on functional ability of a person in the long term care setting. This is a big part of your assessment.
Common Seating Systems
There are an array of seating systems.
- Manual, non-rigid
- Manual, rigid
- Tilt in space
- Bariatric/Heavy duty
- Standard transports
- Comfort based
- Motorized (Rear, Front, Mid)
- Scooter (3 or 4 wheeled)
There are rigid chairs that are considered ultra light wheelchairs, and there are also manual non-rigid chairs, which are also considered ultra light. The main difference is primarily the folding ability of each. They both fold, but in two very different ways. We need to look at their transportation needs to see if they need the smaller dimension. The top two pictures on the right are the ultralight foldable models. Other manual wheelchair options include reclining wheelchairs, tilt in space wheelchairs, and bariatric or heavy duty wheelchairs. These are primarily used for those individuals with morbid obesity or any other issue requiring a stiffer frame or a higher weight capacity. We also have narrow chairs, more of the sports-themed chairs, which are extremely fitted. Moving on, we have standard transport wheelchairs, which are really just point A to point B, not really meant for long distance or independent mobility and can be easily acquired through a vendor or manufacturer. We also have wheelchairs that are comfort based, and we will describe those a little later. There are multiple types of motorized wheelchairs, but the three major types include a rear wheel drive, front wheel drive, and mid-wheel drive motorized wheelchair. We will talk about the differences coming up as well. Lastly, we have scooters. They come in either a three-wheeled or four-wheeled version. Both play a big role in a long term care setting, but both are also very clinically different, especially when matching it to a client's needs.
Manual (Non-Rigid and Rigid)
Figure 1. Examples of manual seating systems.
One quick way to determine whether a wheelchair folds is looking at the mechanical feature right in the middle called the X frame (top right picture). Now this X frame provides a level of rigidity, but also allows a chair to be transported by folding it right in half. The top middle picture shows another ultra light manual standard wheelchair. It is a little harder to tell, but you can see an X-frame right down the bottom. This is not your typical box frame or tubular frame, which is usually associated with a non-foldable or rigid manual wheelchair. The top left picture shows a tilt in space wheelchair. It tilts on its own axis, moving the person as one unit, thus reducing shearing. This is opposed to having the back come down first and then tilting afterwards. As you can see the rear tires are very small, and clearly It has no hand rims on the rear tires. This wheelchair is primarily used for seating and positioning, posture, comfort, tone reduction, or pressure ulcer prevention. Since there are no hand rims on the tires and the tires are actually small in diameter and size, it is not really used for mobility purposes. A wheelchair technically does not have to be used for mobility purposes, but it does have to meet the person's medical needs. On the bottom middle picture, we have a PDG product, which is a local company on the East Coast. They make tilt in space manual wheelchairs. This is a tilt in space manual wheelchair has a much larger rear tire and hand rim, thus the wheel allows a person to use this wheelchair while tilted for mobility. Both of the tilting wheelchairs serve the same purpose of assisting and positioning, but one you are able to mobilize, and the other you are not. On the bottom right is a Broda chair, a very common wheelchair seen in a long term care facility. Broda is a great company from Canada. They make great products, but their products primarily are for comfort. These chairs have four small wheels. Some of them do come with bigger wheels, but primarily they are not meant for propulsion. These chairs do self-tilt and recline, through a pushing force, an actuator from the bottom, or through an attendant control on the back.
Figure 2. Types of motorized wheelchairs.
There is a three-wheeled scooter off to the left as compared to a four-wheeled scooter off to the right. On the bottom right, we have an example of a front wheel drive motorized wheelchair. On the bottom left, we have a rear wheel drive motorized wheelchair. I personally feel the most common variation of the motorized wheelchair is the mid-wheel drive motorized wheelchair (middle pic). A three-wheeled scooter is a mobility device covered by Medicare Part B as a DME and needs to be medically justified for an individual. Scooters are used for community purposes, outdoor mobility, and can be used for indoor mobility as well. The primary difference between a scooter and a motorized wheelchair is that a scooter usually comes with an off-the-shelf captain's seat or a non-complex rehab seating system. You cannot switch out the cushion if somebody has the potential to have a pressure ulcer, for example in the case of severe kyphosis or scoliosis, it is quite difficult to get an after market or custom seating system for a curved back rest for a scooter. A captain's seat is a comfortable seat, but does not accommodate anomalies in posture, alignment, or comfort. Scooters also use either three or four wheels. Power comes from the base right below the seat and most commonly drives the rear wheels, while the front wheel is really used for control. Accessories include mirrors and baskets. Now, a three-wheeled scooter has a much smaller turning radius, while the four-wheeled scooter definitely needs more space. The four-wheeled scooter has a better center of gravity due to the four wheels for support, and the weight right down the middle. A three-wheeled scooter has the center of gravity towards the back and is a little bit more vulnerable to tipping over.
There are different wheel options for a power wheelchair: a mid-wheel (middle), a rear-wheel drive (bottom left), and a front-wheel drive (bottom right). The mid-wheel drive (center picture) is a very common system here that most individuals use. With a mid-wheel drive, you have the primary propulsion coming from the mid-wheels, and the front and rear casters are your trailing wheels, allowing you to turn and maneuver sharp angles. The primary benefit of a mid-wheel is its ability to turn in its own footprint. This is great for institutional and outdoor use. The center of gravity, or the primary weight, is located right above the mid wheels. The difference between scooters and motorized wheelchairs are that you can have a variation of the seating system, so a different type of cushion, backrest, and even a different type of access to control the motorized wheelchair. Other options with a power wheelchair include the ability to hold an augmented communication device, accessories, and medical devices like a ventilator. You can modify a motorized wheelchair to meet the person's needs over time, whereas a scooter is primarily the way you see it now.
Figure 3. Types of wheelchair accessories.
I am going to go around the slide. In the top middle are wheelchair padded gloves. On the right top picture is an arm trough. The bottom right picture shows adductor positioning straps. Next to that is an example of a foot box, and next to that is an example of an elbow pad (in blue). In the bottom left picture is a wheel lock extension. Finally on the top left, there are lateral supports hooked up to a contoured back rest. When we get a brand new car, we want often want accessories, like rims, sunroof, and keyless access. It is the same concept for wheelchairs, but the accessories need to meet the functional needs of individuals. Why would somebody need a padded glove for a wheelchair? If they had neuropathy or a skin issue, these would be a good option. Another condition would include carpal tunnel syndrome. Padded gloves are quite essential for an active wheelchair user more or less for comfort, and as well as for protection. Another example is an arm trough. We prescribe arm troughs for either positioning to assist a person who might have some type of lean or weakness on one side, as well as for an individual who just recently had a CVA to protect the upper extremity. An arm trough can help to stabilize an upper extremity in a specific position, allowing joint protection during mobility, as well as to keep it elevated. I have a lot of individuals that can really benefit from wheel lock (brake) extensions. These are hard to locate as they are very small. These help a person visually access the wheelchair brakes in a very quick and safe way. They also do come in different variations; one has a large, bright ball on the end. Elbow pads can protect their bony prominences. Skin integrity is always an issue, thus an elbow pad, is a way we protect the olecranon process. Positioning belts can help with those that sit in extreme abduction of the hips to reduce bumping into things. On the top left picture, there is a contoured back rest with laterals. Laterals help significantly when addressing the most optimal positioning for a person using a wheelchair. These laterals help in stabilizing the trunk during upright sitting, address leaning towards one side if an individual has some form of hemiparesis, and can assist in optimizing respiratory functions. A proper position will help a client's chest expand and deflate. Foot boxes come in two variations; either a single or double, or a platform. The platform is commonly used to protect the lower extremities. They are great for someone with an internal or external rotation of the ankle, a plantar flexion deformity, a dorsiflexion deformity, an individual who is susceptible to skin tears, or any type of issues in the toes. Foot boxes can be well-padded and you can customize with foam or gel if needed. This device does require a technician or a vendor to come by and install them, because most leg rests and footplates are very different, and these straps come in different variations. The downside of a foot box is that it does make transferring a little bit difficult. I commonly use this for individuals who are total transfers, meaning they are lifted using an overhead lift, but they do require lower extremity positioning. A reclining system on a wheelchair opens the back angle, and it allows a person to offset pressure as well. The only problem with reclining systems is that it changes their poster from that 90 degree hip angle. You need to make sure they have good pelvic support so they do not end up in a slouched posture. A tilt in space chair moves the person as one unit, thus reducing any change in posture.