rolling for success! - sunrise medicalmarketing.sunrisemedical.com/education/goinggreen/... ·...
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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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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
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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.
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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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Vertical Wheel Position
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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Vertical Wheel Position
• 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
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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
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