Archive for the ‘Clinical Seating Mobility Network’ Category

Case Study: Comfort Company Vicair Cushion

Wednesday, May 2nd, 2012





Client Name:  John Doe Patient

Current Wheelchair: New Quickie Q7 Ultra Lightweight (2 Months Post Delivery)

Current Seating on New W/C: Adjustable Tension Back Upholstery with Roho Contour Select Cushion

Clinical Facility: Hill Country Regional Hospital-Inpatient Rehab/Wound Care Clinic

Pressure Mapping System: Vista Medical FSA UT1010-7306


Client is a mid-thirties male who presents with Lower Extremity Paralysis (Paraplegia) due to previous brain stem cerebral vascular accident post approximately 6 years. Slight scoliotic curve at lower/mid thoracic region. Active spasticity in bilateral lower extremities. Very good upper torso balance and very good upper extremity strength most in part from self-propelling previous wheelchair for all activities of daily living. Client lives independently in accessible modular home with son within mostly accessible subdivision and exterior environment.  Client maintains full time employment at regional hospital facility and is very active within the community. Previous wheelchair used was TiLite Titanium Rigid Frame Ultra Lightweight wheelchair with Sling seat and adjustable tension upholstery. Wheelchair cushion utilized was Jay Seating Jay 2 Standard Profile Cushion.

Previous wheelchair was in need of refurbishing as well as seating was no longer supportive in lower lumbar region, cushion was deteriorated and client was experiencing pain, discomfort and redness in right gluteal/ischial tuberosity. Client also complained of early fatigue during the course of the day.

New W/C Application

New Quickie Q7 Ultra Lightweight Wheelchair was specified and measured for proper fit. Standard equipment included: Tubular armrests, anti-tippers, clothing guard/panels and integral push handles. Optional equipment included: Flip up footboard for ease of transfers and positioning lower extremities, adjustable angle-flip down back for ease of transporting. Non-flared front end due to physical stature of client and risk of impact to frame. Flat free inserts were also supplied due to history of flats on previous w/c wheels. Cushion utilized with delivery of new W/C was Crown Therapeutics ROHO Contour Select Adjustable 4 Compartment Cushion for maximum pressure relief as well as lower extremity positioning.  Client requested adjustable tension back upholstery for adjustability and support even though a modular low profile back was discussed and recommended. New W/C was delivered in January 2012.

Post Delivery Concerns

After 2 months of daily use client made contact to discuss possible concerns of new chair and seating. Client continued to complain of pain, discomfort in right side lower torso although not as severe as previously stated. Continued fatigue late in day accompanied by lower back pain/discomfort.  Upon visual inspection of seating posture, client was found to be “sacral sitting” with posterior pelvic tilt as well as slight, right lower extremity adduction.  Client was positioned too far to back of chair. Observations made included inappropriate posterior thoracic support at lumbar and lower thoracic spine from adjustable tension back upholstery. ROHO Contour Select cushion, even though correctly inflated and adjusted for proper positioning of lower extremities was still not completely eliminating discomfort in right IT even with regular pressure relieving by client. Client was in wheelchair for approximately 8-12 hours a day and continued to be fatigued by end of work day. Client rated new wheelchair and seating at a 6-7 on a scale of 1-10 compared to previous wheelchair and seating which was ranked at 2 before new application.


After observations and discussions it was decided to replace the adjustable tension sling back with a modular back for rigidity and extra support of lower thoracic/lumbar area thereby reducing strain and fatigue from sitting and self-propelling throughout the day. It was also decided to try a different pressure reducing/positioning cushion with the same seating medium used with the Roho Contour Select which was air. Products chosen were: Comfort Company  12” Tall Actaback with Adjustable Stays for increased lumbar support and Comfort Company Vector Cushion with Vicair technology.  Modular back was installed and positioned for client comfort as well as maximum lower thoracic/lumbar support while sitting and propelling.  Vector cushion was adjusted for lower extremity support as well as maximum pressure relief in sacral/IT areas, paying particular attention to right side compartments of cushion. A pressure mapping session was determined to be crucial in determining if there was any “loading” of client’s right side while in seated position. Client was advised to use new components while mapping system was secured for further assessment.

Client used new seating components for 2 weeks while mapping system was acquired and session was scheduled.  Upon re-evaluation of client at 2 week mark there was marked improvement in pain and discomfort in right side of seating area as well as reduced fatigue and more stamina throughout day. Upon visual inspection of client while seated and propelling, posture and pelvic positioning had improved tremendously and client was seated in slightly forward of midline position which he stated he was able to maintain throughout the day due to back support. This posture allowed client to exert maximum thrust on wheels with his upper extremities instead of relying on upper torso leverage thereby reducing fatigue and increasing stamina throughout day.

Pressure Mapping of Cushions

It was decided to proceed with the pressure mapping session to solidify the presence of increased pressure in clients right IT area while using both cushions during the mapping session to attain the best results and utilize the cushion with the most support as both were adequate for positioning of the lower extremities but the Comfort Company Vector seemed to alleviate 80-90% of pressure related pain and discomfort.

A Vista Medical FSA UT1010-7306 Pressure Mapping Interface System with FSA Flexible Pressure Wheelchair Mat was utilized for mapping sequence conducted at Hill Country Regional Hospital in the Inpatient Rehab/Wound Care Clinic with clinical staff present. Client switched to Roho Contour Select Cushion which was reassessed and inflated to proper pressures for maximum support and positioning and “pressure map” was captured.  Client then switched to Comfort Company Vector Cushion which was used with previous adjustments and currently utilized by client for daily use. The Comfort Company Vector Cushion was then “captured” by mapping sequence.

After mapping had been completed and compared it was noted that client had a moderate/severe pressure or “loading” area while seated in Roho Contour Select Cushion which was unable to be improved even with multiple adjustments to pressure within the select compartments of the cushion. On the other hand, while seated in the Comfort Company Vector Cushion, the “load” area was noted but to a much lesser extent with even distribution of pressure gradients throughout the area in question.  Both cushions were “mapped” on new Quickie Q7 with Comfort Company Actaback installed and adjusted.


The right combination of seating components were successfully integrated with new wheelchair frame to offer client comfort, support and correct posture while he is seated for extended hours every day.  It was discovered on further assessment that client also had a slight right side scoliosis at the mid-thoracic area which was associated with the “loading” or increased pressure on the right IT/gluteal area.  Once this condition was addressed and properly supported with modular back and lumbar support was increased to compensate for the posterior pelvic tilt, the loading area was decreased but not to the point that it was properly supported with the Roho Contour Select Cushion.  The Comfort Company Vector with Vicair Technology proved to be the better choice for client to evenly distribute surface pressure across the entire cushion area while maintaining lower extremity positioning to prevent adduction.  Client reported less pain and discomfort and more stamina with less fatigue at end of day with the combination of Comfort Company Actaback and Comfort Company Vector Cushion. Pressure mapping of both cushions clearly illustrate the right side “loading” area on the Roho Cushion versus the Comfort Vector Cushion as well as the lower overall average “pressure” gradient across the entire sitting area on the Vector compared to the Contour Select.

Results from ROHOResults from Vicair

Q6 Edge Power Wheelchair: Active American Mobility

Friday, October 21st, 2011
By Patrick Boardman
Active American is pleased to announce a new product from Quantum Rehab called the Q6 Edge. This new wheelchair is a next generation chair that will meet a wide variety of power wheelchair applications. See specs below video:

▪ Mid-Wheel 6® allows six wheels on the ground for
maximum stability
▪ Compatible with TRU-Balance® Power Positioning
▪ Low impact OMNI-Casters (nylon, spherical-shaped casters)
on front and rear prevent wheel hang-ups
▪ ATX Suspension (Active-Trac® with extra stability)
incorporates front OMNI-Casters for enhanced
performance over more varied terrain
▪ TRU-Balance® Lift & Tilt
▪ TRU-ComfortTM Seating
▪ Q-Logic EX Drive Controls
▪ 6 mph motor package
▪ Accu-Trac advanced
tracking technology 6
▪ Power elevating seat

1) Range and speed vary with user weight, terrain type,
battery charge, battery condition and tire pressure.
2) Due to manufacturing tolerances and continual product
improvement, this specification can be subject to variance
of + or – 3 %. Dimensions listed are for power base only.
Overall measurements will vary based on seating and
accessory selections.
3) Tested in accordance with ANSI/RESNA, WC Vol. 2, Section 4,
standards. Results derived from theoretical calculations based
on battery specifications and drive system performance. Testing
conducted at maximum weight capacities. This specification
can be subject to a variance of +10%, -5%.
4) Battery weight may vary based on manufacturer.
5) Optional.
6) Call for availability.
7) Available as part of Community Use package with 6 mph
motors. Increases width by 1.5”.

HCPC Codes for Q6 Edge
Q6 EDGE 3S – SS (Code: K0848)
Q6 EDGE 3S – C (Code: K0849)
Q6 EDGE 3SP – SS (Code: K0856)
Q6 EDGE 3SP – C (Code: K0857)
Q6 EDGE 3MP – SS (Code: K0861)
▪ Articulating vent tray 6
▪ Compact vent tray 6
▪ LED full lighting package
▪ 4” wide flat-free knobby
extended traction tires 6,7
▪ WC19 transit securement
package 6,8
▪ Semi-independent

Designing Technology for People with Dementia-Assistive Technology

Wednesday, October 19th, 2011

Designing Technology for People with Dementia
Stephen Lindsay, Patrick Olivier, Louise Robinson
Newcastle University
Andrew Monk
University of York
Dementia and the ageing population

In recent years in the western world improvements in the quality of life have lead to much greater life expectancies amongst the general population (Arbeev, Butov et al. 2004). With this increase in life expectancy, a shift has occurred in the demographic of Britain, leading to a phenomenon referred to as the aging population. With this shift comes a dramatic increase in the diseases and syndromes associated with old age such as dementia (Ferri, Prince et al. 2005).
Dementia is a severe debilitating condition and, people with dementia experience a global decline in cognitive function leading to problems with memory, perception, reasoning and temporal and spatial awareness (Whitehouse 1993). In addition to these cognitive impairments, those who suffer from dementia can come to suffer from distressing and potentially dangerous behaviours such as wandering, a behaviour where the sufferer performs movements for no apparent reason ranging from restless walking around the home to becoming lost in the community, and aggressive behaviour towards others ranging from verbal to physical aggression (James and Swann 2001).

Over the course of the cognitive-decline that dementia causes, people with dementia come to rely on others to provide care for them, typically a spouse or adult child. This caregiver suffers great deals of stress and anxiety arising from the burden of care placed upon them. The caregivers can also suffer from heavy requirements placed upon their time and consequentially, their personal finances (O’Shea 2003). It is estimated that in Britain, the annual cost of caring for people with dementia is four point six billion pounds, it is anticipated that with the increasing number of sufferers, the cost is anticipated to rise to nearly ten billion in the next forty-five years (Comas-Herrera, Wittenberg et al. 2005). One final driver for research and development of new methods to assist in the care of people with dementia is the relative decline in the numbers of people available to care for the older population. As the balance shifts towards the older population, there will be less and less people under the age of sixty available to care for the older person.

It is within this context that we are examining the potential for assistive technologies to be used in order to promote the independence of individuals with dementia. In particular, our goal is and to enable them to re-claim some their of the sense of self. which dementia can rob a person of. Within this work, the use of communication technologies plays a key role, allowing for compensation for the fact that now many caregivers have competing commitments forcan not spend all their time and often eitherwith their charge and may live in a separate home or spend significant amounts of time in some other form of employmentbe at work during the day.

The use of communication technologies for people with
dementia Two examples of the ways in which communication technologies can and are used to enrich the lives of people with dementia and to relieve the burden that is placed on the caregiver are telecare and mobile communications technology. Both technologies illustrate how improvements in communication technologies can have profound impact on the lives of people with dementia and those that care for them. Telecare: Currently within the care sector, extensive use is made of Tele-care systems. Tele-care involves the use of communication technologies to alert manned call centres to emergency needs of elders. Systems range from those which can be activated by pulling cords installed in the home in areas where problems might arise such as the bathroom, to sensor systems located on the body which are capable of detecting when the user falls and sending alerts to get help to them. Tele-health is a relatively new term that refers to the advent of distributed health care using electronic monitoring tools, this technology allows a doctor to monitor a patients health remotely whilst still communicating personably with the patient via the medium of their television set. The ability to remain in the home, whilst receiving personal medical care via communication technologies, provides an example of the promotion of independence for elders with any condition which might limit mobility.

Mobile communication technologies: Several major trials have demonstrated the
efficacy of tracking for people with dementia, even people who do not typically suffer from the specific behaviour of wandering are still at risk of becoming lost due to forgetfulness and disorientation. The main challenge that faces this technology is not in fact the challenge of tracking but one of developing systems which are ethically and legally sound and secure. Trials which prototyped GPS concluded that, from a technological standpoint, the systems where feasible for use when tracking a person with dementia (Shimizu, Kawamura et al. 2000; Miskelly 2005). The sensors used in both projects did appear to be somewhat cumbersome, strapping a mobile phone on the chest or having the participant carry a bag with them, but both systems provided results that where deemed as being sufficiently accurate and reliable even under adverse conditions.
Research Hypothesis and Area’s of Development

The driving principle behind all the work that we will be doing during the project is that of including people with dementia and their caregivers in the design work. The project aims to include them via the mediums of interviews and focus groups initially, with testing done at a later date in the home. We believe that the inclusion of people with dementia at the design stage, something rarely attempted prior to now, will lead to technologies which do not suffer from any of the problems which other studies have discussed arising from usability problems and a lack of familiarity with what younger generations might consider to be basic paradigms of human computer interaction (Gregor, Newell et al. 2002).
Tracking for Wandering and People with Dementia at Risk of Becoming Lost:

Our goal in the field of tracking people with dementia is to develop socially sensitive tools which enable the user to experience independence from their caregiver again. We believe that by allowing this, the elder life will be enriched by the experience of reclaiming a freedom previously lost to them and the caregivers quality of life will likewise be increased as a result of the reduction of the burden of care put on them. In order to achieve a tracking system that genuinely meets users needs, we will work closely with people with dementia, to this end, we will run focus groups to elicit the feelings of people with dementia towards this tracking and will take account of these feelings in the design of the system. We foresee that their will be a demand for flexible tracking systems which can associate themselves with meaningful area’s based upon the person with dementia and their caregivers perception of the environment that they live in.
We intend to develop tools that aim to allow the user of a system to express these areas’s as they perceive them and will focus on this area in preference to the more technological area’s looking at how to realise the tracking and communication. This will raise challenges when it comes to eliciting information from the person with dementia around the area’s of ensuring that they can associate the area’s as presented to them by the system with the area’s as they move through them in real life.

Supporting The Ambient Kitchen: We are currently developing an ambient kitchen in Culture Lab. This is a mock-up of an actual kitchen in which we embed a number of working demonstrations of the potential for ambient assisted living. The kitchen will provide a platform for explaining and exploring the application of pervasive technology in a domestic setting. Elements of the physical environment they attempt activities of daily living and appliances will be highly instrumented, both with sensors (e.g. accelerometers) and different wireless communication technologies (motes and RFID tags) which will allow both wireless collection of the data and location sensing through the use extensive instrumentation of the artefacts in a kitchen.

An ongoing topic of research in pervasive computing is the unobtrusive recognition of user actions using sensor networks, that is, the identification of activities, manner of performance, and intermediate states in the performance of an action. By building on past approaches, the project will explore the use of both layered probabilistic representations and decision tree classifiers in developing an activity recognition framework that is appropriate to the nature of situated cognitive assistance required. This work will be augmented by a detailed exploration of typical errors which people with dementia make as they attempt activities of daily living and through the use extensive instrumentation of the artefacts in a kitchen. Upon the identification of possible errors, the ambient kitchens various output devices will be used to provide prompting for the user thus avoiding the need for direct user input and achieving a “vanishing” interface” (Orpwood, C.Gibbs et al. 2005).

The manner in which the prompt is delivered will be flexible to account for the wide variations in the cognitive capabilities of the user. Here crossmodal and multimodal prompts have an additional value as they have the potential to allow for possible deficits in one or more of the senses (Gregor, Newell et al. 2002). Previous studies have shown that recorded voice prompting, embedded characters and subtle location cues can all be of use in such systems, the situated nature of the prompts leading to a simulation of implicit prompts (Kautz, Fox et al. 2002 ) but with the option of detecting failure to act upon the prompt so moving on to a more detailed level of cuing (Mihailidis, Barbenel et al. 2004). The ambient kitchens prompting systems will be able to avoid the distress that other less well provisioned systems have caused as a result of false alerts (Adlam, Faulkner et al. 2004; Adlam and Orpwood 2004) due to the more complete and complex nature of the sensors embedded in the environment.

We believe that the two research area’s detailed above, along with an examination into the nature of prompting, provide an excellent inroad for the development of enabling technologies for people and will also afford insights into the nature of working with people with dementia for design purposes. We hope to develop guides to good practice that will provide a basis for future work with people with dementia whilst at the same time demonstrating the value of their inclusion via the development of novel, sensitive technologies.

Adlam, T., R. Faulkner, R. Orpwood, K. Jones, J. Macijauskiene and A. Budraitiene
(2004). “The installation and support of internationally distributed equipment
for people with dementia.” IEEE Transactions on Information Technology in
Biomedicine 8(3): 253-257
Adlam, T. and R. Orpwood (2004). Taking the Gloucester Smart House from the
Laboratory to the Living Room. 3rd International Workshop on Ubiquitous
Computing. Atlanta Georgia.
Arbeev, K. G., A. A. Butov, K. G. Manton, I. A. Sannikov and A. I. Yashin (2004).
“Disability trends in gender and race groups of early retirement ages in the
USA.” Social and Preventive Medicine 49(2): 142-151.
Comas-Herrera, A., R. Wittenberg, L. Pickard and M. Knapp (2005). Cognitive
impairment in older people: its implications for future demand for services
and costs., PSSRU.
Ferri, C. P., M. Prince, C. Brayne, H. Brodatty, L. Fratiglioni, M. Ganguli, K. Hall,
K. Hasegawa, H. Hendris, Y. Huang, A. Jorm, C. mathers, P. R. Menezes, E.
Rimmer and M. Scazufca (2005). “Global Prevalence of Dementia: A Delphi
Consensus Study.” The Lancet 366(9503).
Gregor, P., A. F. Newell and M. Zajicek (2002). Designing for dynamic diversity:
interfaces for older people. ACM SIGACCESS Conference on Assistive
Technologies archive: Proceedings of the fifth international ACM conference
on Assistive technologies. Edinburgh, ACM Press.
James, I. and A. Swann (2001). Dementia: Management of behavioural and
psychological symptoms, Oxford University Press.
Kautz, H., D. Fox, O. Etzioni, G. Borriello and L. Arnstein (2002 ). An Overview of
the Assisted Cognition Project. AAAI.
Mihailidis, A., J. C. Barbenel and G. Fernie (2004). “The efficacy of an intelligent
cognitive orthosis to facilitate handwashing by persons with moderate to
severe dementia.” Neuropsychological Rehabilitation 14,(1-2): 135 – 171.
Miskelly, F. (2005). “Electronic tracking of patients with dementia and wandering
using mobiloe phone technology.” Age and Ageing 34: 497-499.
O’Shea, E. (2003). “Costs and Consequences for the Carers of People with Dementia
in Ireland.” Dementia 2: 201-219.
Orpwood, R., C.Gibbs, T. Adlam, R. Faulkner and D. Meegahawatte (2005). “The
design of smart homes for people with dementia – User-interface aspects.”
Universal Access in the Information Society 4(2): 156-164
Shimizu, K., K. Kawamura and K. Yamamoto (2000). Location System for Dementia
Wandering. 22nd Annual EMBS International Conference, Chicago IL.
Whitehouse, P. J. (1993). Dementia, F. A. Davis Company.

Example Letter of Medical Neccessitty for Sleepsafe Bed and Wheelchair

Wednesday, October 19th, 2011


The following example letter of medical necessity and advice are only intended to assist you in writing your own letter to aid in securing funding for medical equipment. It is in no way implied that if you use this example you will be granted funding for medical equipment. Our only intention is to share information that we have gathered in the past and used by other clients.

The funding agencies that would be in charge of compensation for such medical items, such as your insurance company or a private philanthropic organization, almost always demand a letter of medical necessity from a therapist (physical, occupational, or otherwise) or from a physician to prove your claim that your child’s medical equipment was necessary to his successful treatment. The claim or appeal will be likely be refused if you do not include a letter of medical necessity which includes a detailed explanation of the condition or disability that makes the equipment a necessity for your loved one.

It is possible that your particular physician may not fully be acquainted with the rules of your insurance company which will affect whether or not you are reimbursed for your child’s medical equipment. (Each insurance company or state may have slightly different rules.) To be on the safe side, educate yourself on the rules so that you can be a better advocate for your family. You should become familiar with the bare minimum of information that needs to be included in a letter of medical necessity. Otherwise, the letter may contain insufficient information, which may lead to the funding agency denying your claim.

The following is an example of a thorough and professional letter of medical necessity taken from Dr. Freeman Miller’s Cerebral Palsy: A Complete Guide for Care giving. If you prefer, you can take a copy of this letter to the physician who is writing your child’s letter of medical necessity, and ask that he or she adhere to the example letter below.

“To Whom It May Concern (or, better, to a specific employee of the funding agency):

John Smith is a 5-year-old male with a primary diagnosis of cerebral palsy. He was seen at the Seating Clinic at the John Doe Institute in Anywhere, USA, on June 23, 2007, for the prescription of a bed system to meet his resting needs.

John presents with the following: generally decreased tone in upper and lower extremities, and fair head and trunk control. He is dependent in transfers and mobility. He is cognitively severely delayed. He is incontinent in bowel/bladder. He has frequent respiratory complications and is subject to bronchitis and pneumonia, and he receives chest therapy. He occasionally aspirates, he has increased skin sensitivity, and he has seizures, but they’re generally under control with his medication. He must have safe sleeping environment to eliminate the danger of falls and entrapment with appropriate positioning to provide safety and support, and to facilitate safe sleeping, breathing and feeding.

His current bed is a ___________ that is three years old. It no longer meets his bedding needs because he has outgrown it, and it poses safety concerns because_____________________.

The goals for John’s sleeping and resting is to provide a safe sleeping environment where falls and entrapment no longer pose a threat for harm and to foster a comfortable rest, maintain posture, provide comfort, and enhance function. Upon evaluation, _____________________ has recommended that the following equipment be prescribed for John:

(Be very specific in the bed model, size, and specific safety features)

the following example is for a wheel chair…rewrite this section to detail all of the specific features of the recommended bed system….for example…the Sleep Safe 2 Plus model is prescribed because it offers 22 inches of safety rail height protection above the mattress, eliminating the risk of a fall when he is in a sitting position. The “plus” model frame is prescribed because he is dependant on tube feedings and his head must be elevated during this time….etc)

The ____________________(is prescribed because it is a manual wheelchair for total positioning, and because he is dependent in mobility. The tilt is needed because he is hypotonic in head and trunk. He also has difficulty breathing, and it will help aid in feeding. It will help with low endurance and pressure relief, and it will control seizure reaction. The adjustable height arms are needed to support tray at right height, for upper body support and balance, and for ease of transfers. The I-back will bring side supports close to trunk, but insert will fit the full width of the wheelchair. The laterals will encourage midline trunk position, compensate for lack of trunk control, provide safety, and contour around trunk for better control. The chest harness is needed for safety in transport by providing anterior support, preventing forward flexion, and retracting shoulders. The headrest is needed for poor head control due to low tone, active flexion of head, posterior lateral support, safety in transfers, and to facilitate breathing. The clear tray is needed for functional surface for schoolwork, stimulation, upper arm and trunk support, inability to access tables, computer, and a base for augmentative communication devices. The shoe holders are needed to control increased extension or spasms in lower extremities, excessive internal rotation, and to prevent aggressive behavior for safety. The anti-tippers are needed for safety.

Should you have any questions regarding these recommendations, please do not hesitate to call me at (555) 555-5555. We hope that you will be able to accommodate these needs in an expedient manner. Thank you for your cooperation and assistance in this manner.


John Doe

Be sure to take note of when your child’s letter was sent to the funding agency, and if three or four weeks pass without word from them, you might want to call the agency to inquire about the status of your claim. Always keep a record of when you call and with whom you speak to, and always try to remain calm and collected when dealing with the insurance company. If, however, you are unable to obtain a straightforward response as to when your claim will be processed, do not hesitate to enlist the help of your physician.

RESNA Position on the Application of Wheelchair Standing Devices

Wednesday, October 19th, 2011

RESNA Position on the Application of Wheelchair Standing Devices
RESNA Position on the Application of
Wheelchair Standing Devices
Rehabilitation Engineering & Assistive Technology
Society of North America
1700 N. Moore Street, Suite 1540
Arlington, VA 22209
Phone: 703-524-6686
Fax: 703-524-6630
Approved by RESNA Board of Directors March 2007
RESNA Position on the Application ofWheelchair Standing Devices 2
RESNA Position on the Application of Wheelchair Standing Devices
Clinical experience suggests that wheelchair users often experience painful, problematic and costly secondary complications due to long term sitting. Standing is an effective way to counterbalance many of the negative effects of constant sitting 1,2. Standers integrated
into wheelchair bases enhance the beneficial effects of standing since they allow for more frequent, random and independent performance of standing than in persons who use standing devices outside of a wheelchair base. Integration of this feature into the wheelchair base also enables standing to enhance functional activities.

It is RESNA’s position that wheelchair standing devices are often medically necessary, as they enable certain individuals to:
 Improve functional reach to enable participation in ADLs (Activities of Daily
Living (i.e. grooming, cooking, reaching medication)
 Enhance independence and productivity
 Maintain vital organ capacity
 Reduce the occurrence of Urinary Tract Infections
 Maintain bone mineral density
 Improve circulation
 Improve passive range of motion
 Reduce abnormal muscle tone and spasticity
 Reduce the occurrence of pressure sores
 Reduce the occurrence of skeletal deformities, and
 Enhance psychological well being.
Special precautions must be exercised when utilizing standers, in order to avoid the risk of injury, such as fractures. A licensed medical professional (i.e. physical or occupational therapist) must be involved with the assessment, prescription, trials and training in the use of the equipment. The purpose of this document is to share typical clinical applications as well as provide evidence from the literature supporting the application of this seat function to assist practitioners in decision making and justification. It is not intended to replace clinical judgment related to specific client needs.

Definition A standing feature integrated into a wheelchair base allows the user to obtain a standing position without the need to transfer from the wheelchair. A mechanical or electromechanical system manipulated via levers or the wheelchair’s controls moves the seat surface from horizontal into a vertical or anteriorly sloping position while maintaining erticality of the legrests and backrest, thus extending the hip and knee

RESNA Position on the Application ofWheelchair Standing Devices 3 joints.
A full vertical standing position can be achieved directly from sitting, or through gradual angle changes from a laying position, or a combination of these positions. Most wheelchair standers allow for full or partial extension of the hip and knee joints, and full upright or partially tilted positions. Wheelchair standers are available on manual or power
wheelchair bases. Wheelchair standing devices address the following medical and functional needs:
Functional reach and access to ADLs
Standing adds significant amount of vertical access. Since the seating surface moves into a vertical position, typically the amount of additional vertical access equals the user’s seat depth. This allows people to access kitchen cabinetry, light switches, microwaves, mirrors, sinks, hangers, thermostats, medicine cabinets, and many other surfaces to enhance their abilities to perform ADLs, depending on the client’s upper extremity
function. An integrated wheelchair stander system allows for moving about while in a standing position, and standing can become an integral and functional part of the day and the user can perform a variety of ADLs while in the standing position, combining functional and medical benefits. A standing position can be assumed as needed, both for indoors and outdoors activities – it can aid productivity and integration at work, school, church, or enhance independence for example when shopping for groceries. Being able to perform standing from one’s wheelchair also minimizes transfers, thereby enhancing safety, conserving energy and reducing dependency. Research suggests that in addition to expense and lack of awareness, the major reasons for not using stationary standers for
wheelchair users with Spinal Cord Injury (SCI) is time constraints, lack of assistance, and/or lack of space for an extra device2. Passive Range of Motion, Contractures Standing extends the hip and knee joint to provide position change. Animal studies have shown that muscles which were fixed in a flexed position resulted in increased contractures of the joints, especially when the bones are still growing 3,4. Many people in wheelchairs have limited access to therapy or care givers who can provide the necessary amount of ranging – standers integrated with the wheelchair base allow them to perform this important activity on their own and with higher frequency. Standing, however, should not be considered as a substitute for therapy. Vital organ capacity During standing, the pelvis tends to assume a more anterior tilt or neutral position, allowing for an increase in lumbar lordosis as compared to sitting. This in turn helps establish a better alignment of the spine and extend the upper trunk. Extension of the upper trunk results in reduced pressure on the internal organs, thereby enhancing

RESNA Position on the Application of Wheelchair Standing Devices 4
respiratory and gastro-intestinal capacity and functioning. This can prevent or delay many secondary complications so often seen in wheelchair users.
 Respiration. Many users experience improved lung capacity when standing often. Studies have s hown that those who stand frequently in standing power wheelchairs have lesser or delayed occurrence of respiratory complications and improved respiratory volume 2. Standing can help also reduce congestion and coughing 5.
 Gastro-Intestinal problems. Standing wheelchairs users also experienced lesser or delayed occurrence of gastro-intestinal complications, for example via improvement in gastric emptying 1,2.
 Bowel function. Some users have experienced improved bower regularity, reduced constipation, and lesser occurrence of accidental and unregulated bowel movement as a consequence of using wheelchair standers1. Elimination of chronic constipation and significant reduction in bowel care time has also been shown as a result of frequent standing 2,6. Chronic constipation can lead to bowel obstruction, a dangerous condition often requiring surgery. Unregulated bowel movements can lead to fecal incontinence at a time when the client cannot be cleaned by a caregiver, increasing the risk of developing pressure sores.
 Increased Bladder emptying. Users of standing devices reported that they were able to empty their bladders more completely than prior to using the device 1.
Urinary Tract Infections
Urinary Tract Infections (UTI) is the third most frequent complication for clients with SCI 7, and a frequent secondary complication for many other wheelchair users. Prolonged immobility causes hypercalcemia, increased urinary calcium output 8, and also reduces bladder emptying 1. By reducing contributing risks, standingwheelchairs have been shown to reduce the occurrence of UTI for wheelchair users 1, which could lead to kidney

Bone Mineral Density
Many wheelchair users experience significant reduction in Bone Mineral Density (BMD)due to the lack of weight bearing in the lower extremities. In fact, without gravitational or mechanical loading of the skeleton, there is a rapid and marked loss of bone. This results in osteoporosis and risk of fractures. Research suggests that weight bearing is superior to
nutritional supplements in preventing BMD loss, and that the mechanical loading of the bones should be dynamic for full prevention of BMD loss. It also appears that with discontinuation of the weight bearing program, BMD levels will continue to decrease and/or return to pre-weight bearing values. While stationary standers lessen the loss of BMD, wheelchair standers may actually eliminate BMD loss all together, given their ability to provide dynamic weight bearing through the lower extremities. Populations with a variety of disabilities have been studied
RESNA Position on the Application of Wheelchair Standing Devices 5
for loss of BMD, such as children with Cerebral Palsy (CP) or Spina Bifida, as well as adults with Stroke, Multiple Sclerosis and SCI 9. Even if BMD loss has not yet occurred in a user, standing can be an effective mean to help prevent this secondary complication.
 Loss of BMD. Review studies establish the direct relationship between
weightlessness and loss of BMD, as well as the relationship between osteoporosis and the high risk of fractures 10-12. Studies with astronauts and people in bedrest quantify the negative effect of weightlessness and lack of weightbearing on BMD 13-17. This loss can be as high as 36% loss of the cross sectional area of a nonweight bearing bone within a month 18. In bed rest, the average urinary calcium loss at the peak is about -150 mg per day, which corresponds to 0.5 percent of total body calcium 19-21. For people with disabilities, numerous studies point out the benefits of frequent passive standing and weight bearing/exercise on BMD 22-25.
 Fractures and loss of independence. Loss of BMD leads to osteoporosis and the consequent risk of fractures. Articles on children with Osteogenesis Imperfecta recommend frequent standing in childhood to maximize adulthood independence by minimizing fractures and the likelihood of broken bones 26,27. Many people with disabilities often heal slower, as well. Fractures may limit short and long term function.
 Supplements. Evidence suggests that while appropriate nutritional supplements may reduce calcium loss from the bones, mechanical loading is superior to supplements for BMD maintenance18. Dietary changes, such as increased intake of calcium and/or vitamin D, have not proven effective at minimizing disuse bone loss 28.
 Mechanical weight loading. Living bones constantly adapt themselves to the mechanical forces applied to them, and their structure is directly linked to their weight bearing activity and forces occurring due to movement against resistance29. Weight-bearing activity can be thought of as any activity that is done while upright, requiring the bones to partially or fully support the body’s weight against gravity 30. Impact-loading, weight-bearing activity, therefore, involves some impact or force being transmitted to the skeleton during weight bearing. Standing provides mechanical loading through the longitudinal axes of the lower extremity bones. When the body is upright and extended, the bones of the lower
extremities carry the entire weight of the body therefore loading is most efficient. Since the lower extremities normally carry the entire body’s weight, they are the most prone to bone degeneration due to reduced or limited weight bearing.
 Dynamic loading. Further studies clarify that standing is to be dynamic (higher multitude and varied magnitude), in order to fully prevent loss of BMD. According to the scientific literature, static loading is less efficient than dynamic loading in prevention of BMD loss 18, 31-34. A recent study of children with disabling conditions found that a 6 months standing program with a stationary stander still resulted in BMD reduction (-6.3%), while utilizing vibrating plates underneath the standers actually increased BMD (+11.9%) in the subjects 35. This is of utmost importance regarding standing wheelchairs, since they offer dynamic loading in a variety of ways. When using a mobile wheelchair base during

RESNA Position on the Application ofWheelchair Standing Devices 6 standing, vibration occurs due to the movement of the wheelchair applying dynamic loads to the bones of the lower extremities. In addition, small obstacles (such as carpet edges, door thresholds, tile edges, etc.) all provide dynamic input
when the user drives over them. Standers integrated with a wheelchair base also allow for frequent loading of the bones throughout the day by just performing partial standing.
 Maintenance of weight bearing. For the weight bearing exercise to be effective, the mechanical stress placed on the bone must exceed the level to which the bone has adapted (i.e., short periods of intense loading can produce more new bone than long-term routine loading) 36. However, long-term routine loading is important in maintaining bone density. And although bone responds to mechanical loading, it is easier to lose bone through inactivity than to gain more through changes in functional loading. When weight-bearing exercise is not continued, bone mass reverts to pre-training levels 37, 38. With standers integrated into a wheelchair base, the user is not dependent on circumstances (such as caregiver availability) to continue standing. Consequently, maintenance of a
standing program and higher frequency of standing is more likely. Additionally, integrated standers allow for standing nearly any time for any length of time, therefore weight loading is more likely to be of random distribution, which appears to be superior in BMD loss prevention.
Circulation Users have also experienced improvement in lower extremity circulation as a consequence of utilizing a wheelchair stander 2. Some benefits are reduced swelling in the legs and feet. Tone Wheelchair standers also aid in reduction of access muscle tone; research indicates that muscle stretch combined with weight loading reduces muscle tone more than stretching alone (32% vs. 17%) 39. Some users experience tone reduction in their upper extremities due to better skeletal alignment in a standing position. This may translate into improved speech and better hand and arm function to perform ADLs. Tone reduction can improve comfort, minimize further range of motion losses, improve function and conserve energy.
Research studies show that standing wheelchair users have experienced significant reduction in spasticity 1,2. This helps with transfers, can aid in better sleep, reduces fatigue and pain, and improves positioning in the wheelchair. Standing has an immediate and significant effect on spasticity 40.
RESNA Position on the Application ofWheelchair Standing Devices 7
Pressure sores When fully standing, pressure is 100% relieved off the Ishial Tuberosities (ITs). However, when tilting or reclining, there is only partial redistribution of pressure underneath the ITs 41, 42. Pressure ulcers are the primary complication for people with SCI
7, and many other adults who sit in wheelchairs all day long. There is evidence that users have suffered fewer pressure sores while using standers 41, or integrated wheelchair standers1,2. Skeletal deformities
Clinical experience suggests that extension of the upper trunk and proper alignment of the hip during standing helps delay typical skeletal deformities often seen in people who sit in a wheelchair for long periods of time, such as fixed posterior pelvic tilt, kyphosis and scoliosis of the spine, and windswept deformities of the lower extremities. During standing the head of the femur usually ends up better seated in the acetabulum,which is important especially for children, to promote healthy skeletal alignment, as well as to promote proper development of the acetabular socket. Community environments, vocational and recreational benefits Integrated wheelchair standers can benefit users in a variety of community settings to enhance their independence, improve vocational, and enable recreational activities. Examples include but are not limited to:
 Improve ability to reach higher shelves in grocery stores and other shopping facilities
 Ability to access vending machines, payphones, high elevator buttons, coffee shop counters, etc.
 Stand up to access fax machines, drawers, client files, and other necessities at work
 Enable certain jobs which need to be performed from a standing position (such as hotel receptionist, clerical, medical, hair stylist, etc.)
 Enhance recreational activities, for example by standing up with others on a ball game.
Additional benefits
Additional benefits of utilizing an integrated wheelchair standing system include but are not limited to:
 Reduce fatigue due to benefits mentioned earlier, thereby prolonging tolerance to staying in the wheelchair for longer periods of time
 Enable some male users to use a public urinal independently as opposed to
transferring to a toilet or using catheterization
RESNA Position on the Application of Wheelchair Standing Devices 8
 Reduce the need for attendant care by lessening the need to transfer in and out of the wheelchair, the ability to range independently and perform ADLs
 Reduce back pain and risk of injury for caregivers by minimizing the amount of transfers they need to perform
 Partial standing provides an anteriorly sloped femur position, which can translate into a better pelvic alignment and enhanced lumbar lordosis. Clinical experience suggests that some clients find this position to improve their alertness and/or improve their upper extremity function.
 Many children who use mobility equipment throughout the day are on intensive standing programs. They often have a stander at school and one at home. Integrating standing into the wheelchair base reduces the necessary number of equipment, and ensures more frequent and independent initiation of standing.
 Standing up with a tilt table function (gradual angle change into upright) may help alleviate problems with orthostatic hypotension, especially with clients after prolonged bedrest. Psycho-social indications
A standing position can lend wheelchair users a heightened sense of confidence and equality, by enabling eye to eye conversations with the non-disabled society. Many everyday and special occasions in our society require standing; citing of the Pledge of Allegiance at school, graduations, weddings, demonstrations, introductions to people,
religious services, etc. When a person is allowed to stand with everyone else any time (afforded by an integrated wheelchair standing device) there is a much better sense of integration and the disability becomes less visible, self-esteem is enhanced, acceptance by others is perceived to be higher, and depression is often reduced.
In spite of the numerous benefits, a standing wheelchair might be contraindicated without appropriate assessment. Not everybody is an appropriate candidate for standing. Some contraindications and precautions include but are not limited to:
 Existing contractures: the client may benefit from partial weight bearing even if he already has fixed contractures of the lower extremities. However, the amount of extension may have to be limited mechanically or electronically, especially in case of a client without sensation. A wheelchair stander is a powerful device and may cause harm if attempting to overstretch contracted muscles.
 Skeletal deformities: both the sitting and the standing position have to provide appropriate support for stability and function, so special accommodations may have to be provided for people with significant deformities, especially if those deformities are not flexible. Skeletal alignment is to be carefully observed while standing.  If the client has not been standing for a significant amount of time (schedules vary
by person and circumstances), it is necessary to obtain a physician’s approval and
RESNA Position on the Application of Wheelchair Standing Devices 9
trial a stander to assess standing tolerance. Prior examinations might be
warranted, such as X-rays and bone density assessment.
 Existing BMD loss and osteoporosis might cause fractures if attempting to stand
prematurely and without a well designed progressive standing program.
 Postural hypotension: check for blood pressure and dizziness while standing up, especially for new clients with recent injuries.
 Some amount of sacral shearing might occur while standing up or sitting down – attention must be paid to skin integrity in the sacral region.
 Adaptive or custom seating: standing systems will not work with one piece
seating systems (as the seat to back angle changes) or highly contoured seating systems due to shear. Frequency of standing Frequency and duration of standing routines are recommended on an individual basis.
They very by tolerance, fatigue, level of current BMD and functional goals. In general, standing is recommended as long and as often as the user can tolerate comfortably to increase the benefits. Standers integrated into wheelchair bases allow for spontaneous and
frequent utilization of standing. Summary
It is RESNA’s position that wheelchair standing devices are medically beneficial for wheelchair users by: enabling them to reach; improving ADL abilities; enhancing independence and productivity; maintaining vital organ capacity, bone mineral density, circulation and range of motion; reducing tone and spasticity, the occurrence of pressure sores and skeletal deformities; and enhancing psycho-social well-being.
RESNA Position on the Application ofWheelchair Standing Devices 10
Case Examples
JD is a 19 year old male with spastic athetoid quadriplegic Cerebral Palsy. He has been driving a power wheelchair for mobility since he was 6. A power wheelchair with a standing feature was prescribed to him, due to the need for frequent standing, functional goals, to enhance independence and to reduce his mother’s back pain which she has developed due to frequent transfers. After 6 months of use a marked improvement is
noticed in his upper extremity function, his speech and swallowing, as well as his comfort and tolerance to staying in the wheelchair all day.
Larry is a 65 year old gentleman with Multiple Sclerosis for the last 15 years. On initial evaluation he was experiencing significant problems with lower extremity spasticity that interfered with his ability to sit in a wheelchair and to be transferred with the assistance of his wife. He was using a manual wheelchair with a limited seating system and was
developing a severe kyphosis of the spine. He also had issues with bowel and bladder control, lower extremity edema, and poor affect. Following careful assessment and an extensive trial of a stander, he was provided with a power wheelchair equipped with a passive stander as well as tilt in space, reclining backrest, and elevating legrests. At a sixmonth
follow-up assessment he reported standing 4 to 6 times per day for 15 to 30
minutes. He was observed to have significantly decreased lower extremity spasticity to the point where he was no longer taking anti-spasticity medication. His wife reported this further made transferring him safer and more manageable. It also allowed him to have improved bed mobility that allowed him to get a full night’s sleep. There was also no noted edema in his lower extremities and he reported far fewer bowel and bladder
accidents to the point where he was comfortable going out in the community on a weekly basis. He demonstrated improved ability to reach and carry out tasks at different surface heights, was observed to be able to sit more upright with less a kyphosis, and improved affect.

Mr. D. is a 36 year old male with a diagnosis of tetraplegia due to a C7 spinal cord injury. He is the primary caretaker of two young boys and works part time as a barber. In the community, he utilizes a rigid frame wheelchair. A manual wheelchair with standing feature was prescribed for him due to severe complaints of shoulder and upper quadrant pain and decreased upper extremity function. This was due to repeated overhead
activities at home and work. With the manual wheelchair with standing feature he was able to work for longer periods of time and care for his children. The standing feature allowed D to complete activities in his forward plane. This led to a significant decrease in complaints of shoulder pain and improved upper extremity function.

RESNA Position on the Application of Wheelchair Standing Devices 11
1. Dunn, R. B., Walter, J. S., Lucero, Y., Weaver, F., Langbein, E., Fehr, L.,
Johnson, P., & Riedy, L. (1998). Follow-up assessment of standing mobility device users. Assist Technol, 10(2), 84-93.
Survey study assessing the perceived benefits of standing devices userd
by patients with Spinal Cord Injury. Level IV.
2. Eng JJ, Levins SM, Townson AF, Mah-Jones D, Bremner J, Huston G. Use of
prolonged standing for individuals with spinal cord injuries. Phys Ther. 2001 Aug;81(8):1392-9.
Survey study assessing the perceived benefits of standing devices userd
by patients with Spinal Cord Injury. Level IV.
3. Trudel G. Uhthoff HK. Contractures secondary to immobility: is the restriction articular or muscular? An experimental longitudinal study in the rat knee. [Journal Article] Archives of Physical Medicine & Rehabilitation. 81(1):6-13, 2000 Jan. Controlled, experimental study examining the effect of immobility on rat joints. Level II.
4. Trudel G. Uhthoff HK. Brown M. Extent and direction of joint motion limitation
after prolonged immobility: an experimental study in the rat. [Journal Article] Archives of Physical Medicine & Rehabilitation. 80(12):1542-7, 1999 Dec. Controlled, experimental study examining the effect of immobility on rat joints. Level II.
5. Stainsby K, Thornton H. Justifying the provision of a standing frame for home use – a good case to quote. Synapse Spring 1999, pp3-5.
Case study describing the use and reasoning behind providing a
standing frame for a single client. Level V.
6. Hoenig H. Murphy T. Galbraith J. Zolkewitz M. Case study to evaluate a standing table for managing constipation. Sci Nursing. 18(2):74-7, 2001 Summer. Case study describing the use of a tilt table for a single client with SCI. Level V.
7. McKinley WO. Jackson AB. Cardenas DD. DeVivo MJ. Long-term medical
complications after traumatic spinal cord injury: a regional model systems
analysis. Archives of Physical Medicine & Rehabilitation. 80(11):1402-10, 1999 Nov. Review of medical records at various time points post SCI. Level III. RESNA Position on the Application ofWheelchair Standing Devices 12
8. Issekutz B Jr. Blizzard JJ. Birkhead NC. Rodahl K. Effect of prolonged bed rest on urinary calcium output. Journal of Applied Physiology. 21(3):1013-20, 1966 May. Controlled experimental study of the effects of bedrest on urinary calcium output, performed with healthy males. Level II.
9. Thompson CR. Figoni SF. Devocelle HA. Fifer-Moeller TM. Lockhart TL.
Lockhart TA. From the field. Effect of dynamic weight bearing on lower
extremity bone mineral density in children with neuromuscular impairment.
Clinical Kinesiology. 54(1):13-8, 2000 Spring. (30 ref) Questionnaire, comparing BMD of children with and without disabilities. Level IV.
10.Martin AD. Houston CS. Osteoporosis, calcium and physical activity. CMAJ
Canadian Medical Association Journal. 136(6):587-93, 1987 Mar 15.
Review of controlled experimental trials on the effects of calcium intake
and physical exercise. Level V.
11.Martin AD. McCulloch RG. Bone dynamics: stress, strain and fracture. Journal of Sports Sciences. 5(2):155-63, 1987 Summer. Review of controlled trials on the effects of dynamic weight loading in osteogenesis. Level V.
12. Ehrlich PJ. Lanyon LE. Mechanical strain and bone cell function: a review. [Review] [225 refs] Osteoporosis International. 13(9):688-700, 2002 Sep. Review of controlled trials on the effects of mechanical strain on bone cell function. Level V.
13.Whedon GD. Changes in weightlessness in calcium metabolism and in the
musculoskeletal system. Physiologist. 25(6):S41-4, 1982 Dec.
Summary of experience with the effects of weightlessness on calcium
metabolism. Level II.
14.Whedon GD. Lutwak L. Rambaut P. Whittle M. Leach C. Reid J. Smith M.
Mineral and nitrogen metabolic studies on Skylab flights and comparison with effects of earth long-term recumbency. Life Sciences & Space Research. 14:119-27, 1976. Experimental study of astronauts in space. Level III.
15.Whedon GD. The influence of activity on calcium metabolism. Journal of
Nutritional Science & Vitaminology. 31 Suppl:S41-4, 1985 Dec.
Review of the effects of lack of weight bearing and mechanical loading
on BMD. Level V. RESNA Position on the Application ofWheelchair Standing Devices 13
16.Mazess RB. Whedon GD. Immobilization and bone. Calcified Tissue
International. 35(3):265-7, 1983 May Review of the effects of immobilization on bone structure. Level V. 17. Lutz, J., Chen, F., and Kasper, C.: Hypokenesia-Induced Negative Net Calcium Balance Reverse by Weight Bearing Exercise, Aviation, Space, and Environmental Medicine 58:308-314 (1987). Controlled experimental study of rats in hypokinetic situation vs. regular weight bearing. Level II.
18. Lanyon LE. Rubin CT. Baust G. Modulation of bone loss during calcium
insufficiency by controlled dynamic loading. [Journal Article] Calcified Tissue International. 38(4):209-16, 1986 Apr.
Controlled experimental study of turneys on a calcium-insufficient diet.
Level II.
19. Deitrick, J., Whedon, G., & Shorr, E. (1948). Effects of immobilization upon various metabolic and physiologic functions of normal men. American Journal of Medicine, 4, 3. Experkental study of normal males analyzing the effects of immobilization. Level III.
20. Donaldson, C., Hulley, S., Vogel, J., et al. (1970). Effect of prolonged bed rest on bone mineral. Metabolism, 19, 1071.
Experimental study of healthy males. Level III.
21. Hangartner, T.N. (1995, Aug.). Osteoporosis due to disuse. In V. Matkovic (ed.), Physical Medicine and Rehabilitation Clinics of North America: Osteoporosis, 6(3), 579-594, Philadelphia: W.B. Saunders Company.
Review of disuse causes and contributing factors to osteoporosis. Level
22. Kaplan PE. Gandhavadi B. Richards L. Goldschmidt J. Calcium balance in
paraplegic patients: influence of injury duration and ambulation. Archives of Physical Medicine & Rehabilitation. 59(10):447-50, 1978 Oct.
Experimental controlled study comparing two groups of paraplegic
patients and observing the effects of early ambulation post injury on
their calcium balance. Level II.
23. Kaplan, P.E., Roden, W., Gilbert, E., Richards, L., and Goldschmidt, J.W.: Reduction of Hypercalciuria in Tetraplegia after Weight Bearing and
Strengthening Exercises. Paraplegia 19:289-293 (1981). Experimental controlled study assessing tetraplegic patients and observing the effects of weight bearing exercises on their calcium balance. Level II.
RESNA Position on the Application ofWheelchair Standing Devices 14
24. Goemaere S. Van Laere M. De Neve P. Kaufman JM. Bone mineral status in
paraplegic patients who do or do not perform standing. Osteoporosis
International. 4(3):138-43, 1994 May. Controlled non-experimental study of paraplegics who do and not not perform standing. Level III.
25. Kunkel CF. Scremin AM. Eisenberg B. Garcia JF. Roberts S. Martinez S. Effect of “standing” on spasticity, contracture, and osteoporosis in paralyzed males. Archives of Physical Medicine & Rehabilitation. 74(1):73-8, 1993 Jan. Experimental study measuring the effects of standing on paraplegics. Level III.
26. Binder H. Hawks L. Graybill G. Gerber NL. Weintrob JC. Osteogenesis
imperfecta: rehabilitation approach with infants and young children. Archives of Physical Medicine & Rehabilitation. 65(9):537-41, 1984 Sep.
A new rehabilitation program including positioning and stretching
developed and demonstrated on four children with Osteogenesis
Imperfecta. Level V.
27. Bleck EE. Nonoperative treatment of osteogenesis imperfecta: orthotic and mobility management. Clinical Orthopaedics & Related Research. (159):111-22, 1981 Sep.
Early implementation program of weight bearing for children with
Osteogenesis Imprerfecta, and results demonstrated with twelve
children. Level V.
28. Sinaki, M. (1995). Musculoskeletal rehabilitation. In B.L. Riggs & L.J. Melton, III (eds)., Osteoporosis: Etiology, Diagnosis, and Management,435-473. Philadelphia: Lippincott-Raven Publishers.
Review of osteoporosis and its management. Level I.
29. Simkin, A. & Ayalon, J. (1990). Bone-loading: The new way to prevent and combat the thinning bones of osteoporosis. London: Prion.
Review of osteoporosis and the effect of exercise to help combat it. Level
30. Bonnick, S.L. (1994). The Osteoporosis Handbook. Dallas: Taylor Publishing Company. Management of osteoporosis, effect of weight bearing. Level V.
31. Fritton SP. McLeod KJ. Rubin CT. Quantifying the strain history of bone: spatial uniformity and self-similarity of low-magnitude strains. [Journal Article] Journal of Biomechanics. 33(3):317-25, 2000 Mar.
Experimental study analyzing the types and magnitude of strains
occurring on three different species of animals during normal activities.
Level III. RESNA Position on the Application ofWheelchair Standing Devices 15
32.McLeod KJ. Rubin CT. Otter MW. Qin YX. Skeletal cell stresses and bone
adaptation. [Review] [27 refs] [Journal Article. Review. Review, Tutorial]
American Journal of the Medical Sciences. 316(3):176-83, 1998 Sep. comprehensive review of bone adaptation due to skeletal stresses. Level
33. Lanyon LE. Rubin CT. Static vs dynamic loads as an influence on bone
remodelling. [Journal Article] Journal of Biomechanics. 17(12):897-905, 1984. Experimental controlled study assessing the remodeling properties of the avian ulna under various loading conditions. Level II.
34. Rubin CT. Lanyon LE. Regulation of bone formation by applied dynamic loads. [Journal Article] Journal of Bone & Joint Surgery – American Volume. 66(3):397- 402, 1984 Mar. Experimental study assessing the remodeling properties of the avian ulna under various loading conditions. Level II
35.Ward K, Alsop C, Caulton J, Rubin C, Adams J, Mughal Z. Low magnitude
mechanical loading is osteogenic in children with disabling conditions. J Bone Miner Res. 2004 Mar;19(3):360-9. Epub 2004 Jan 27.
Constrolled experimental study assessing the effects of low magnitude
mechanical loading on bone condition in children with disabling
conditions. Level II.
36. Frost, H.M. (1990). Skeletal structural adaptations to mechanical usage
(SATMU)–Redefining Wolff’s Law: The bone modeling problem. The
Anatomical Record, 226, 403-413. Description of bone modeling theory. Level V.
37. Dalsky, G., Stocke, K., Ehsani, A., et al. (1988).Weight-bearing exercise training and lumbar bone mineral content in postmenopausal women. Annals of Internal Medicine, 108:824- 828. Controlled, experimental, non-randomized trial of post-menopausal women and the effect of exercise on their lumbar bone mineral content. Level III.
38. Drinkwater, B.L. (1994, Sept.). 1994 C.H. McCloy Research Lecture: Does
physical activity play a role in preventing osteoporosis? Research Quarterly for Exercise and Sport, 65(3), 197-206.
Review article on the effects of exercise on osteoporosis. Level V.
RESNA Position on the Application ofWheelchair Standing Devices 16
39. Odeen I. Knutsson E. Evaluation of the effects of muscle stretch and weight load in patients with spastic paraplegia. Scandinavian Journal of Rehabilitation Medicine. 13(4):117-21, 1981. Experimental study on the effects of stretching with or without weight loading in paraplegic patients. Level III.
40. Bohannon RW. Tilt table standing for reducing spasticity after spinal cord injury. Archives of Physical Medicine & Rehabilitation. 74(10):1121-2, 1993 Oct. Case study with a single client with SCI on the effect of tilt table use on spasticity. Level V.
41. Hobson D.A. (1992). Comparative effects of posture on pressure and shear at the body-seat interface. J Rehabil Res Dev. Fall;29(4):21-31.
Experimental study on tilt-recline systems and their effect on pressure.
Level III.
42. Aissaoui, R., Lacoste, M., Dansereau, J. Analysis of sliding and pressure distribution during a repositioning of persons in a simulator chair. IEEE Transactions on Neural Systems and Rehabilitation Engineering 2001; 9: 215-224. Experimental study on repositioning and its effect on pressure. Level IV.
43. Janice T. Hunt MS, PT (1993). Standing Tall, Team Rehab, Sept. 17-20
Case study description of a client utilizing a standing wheelchair. Level
V. Sackett model definition of levels: Level I: Evidence is obtained from meta-analysis of multiple, well-designed, controlled studies. Level II:
Evidence is obtained from at least one well-designed experimental study.
Level III: Evidence is obtained from well-designed, quasi-experimental studies such as non-randomized, controlled single-group, pre-post, cohort, time, or matched case-control series Level IV: Evidence is from well-designed, nonexperimental studies such as comparative and correlational descriptive and case studies Level V: Evidence from case reports and clinical examples RESNA Position on the Application ofWheelchair Standing Devices 17 Authors: Julianna Arva, M.S., ATP, Ginny Paleg, PT, Michelle Lange, OTR, ABDA, ATP, Jenny Lieberman, MSOTR/L, ATP, Mark Schmeler, M.S., OTR/L, ATP, Brad Diciano,MD, Mike Babinec,OTR/L, ABDA, ATP
RESNA is an interdisciplinary association of people with a common interest in technology and disability. RESNA’s purpose is to improve the potential of people with disabilities to achieve their goals through the use of technology. RESNA serves that purpose by promoting research, development, education, advocacy and provision of technology; and by supporting the people engaged in these activities. Developed through RESNA’s Special Interest Group in Seating and Wheeled Mobility (SIG-09)

Motion Concepts Wheelchair Back HCPC Codes

Wednesday, October 19th, 2011

Manufacturer Product Name Model Number HCPCS Code Effective Date End Date Comments
















































Medical Justification Sample For Lateral Tilt System

Wednesday, October 19th, 2011

Letter of Justification for J. (Lateral Tilt)

J. is a 62 year-old female with a diagnosis of MS currently residing in The Boston Home. J. was referred to PT for an assessment of seating and mobility needs due to her complaints of excessive need for repositioning in her power wheelchair. She requests assistance 3 to 4 times a day. Her chair is 9 years old and is unable to be modified any further. She complains of difficulty driving her wheelchair in tight spots due to length of system. J. currently uses a Quickie power wheelchair.

J. has a scoliosis that we are unable to support using standard lateral trunk support pads. Although the support pads appear to maintain J. in good alignment, she continues to move out of good alignment when performing functional activities. She frequently requests repositioning of trunk and pelvis. A complete range of motion assessment was performed to determine limitations that affect seating. The following problems were identified: J. exhibits good range of motion in both lower extremities with the exception of some tightness in ankle dorsiflexion. Left foot needs to be positioned in slight plantar flexion to accommodate ankle contracture. J. exhibits a left thoracic trunk scoliosis. She can be straightened on the mat to neutral but is unable to maintain independently. Good mobility noted in pelvis with the exception of inability to achieve a right obliquity. She is able to attain neutral obliquity but her tendency is to shift toward a left obliquity. Head and neck range of motion functional. Trunk scoliosis and pelvic obliquity affect J.’ comfort and ability to maintain good postural alignment when sitting in the wheelchair.

After performing a thorough assessment including assessing range of motion for seating, seating simulation and testing of various equipment, the following has been determined:

Difficulty maneuvering indoors

Chair doesn’t perform to client’ skills

Difficulty maneuvering outdoors

Chair does not laterally tilt

Chair can not be modified due to age

Following is a list of goals for J. to address needs:

Improve ADL skills when in wheelchair including washing, brushing and accessing computer. Improve postural alignment when sitting in the wheelchair for improved comfort. Improve ability to reposition self for increased independence and comfort throughout the day. J.’ current power wheelchair is over 9 years old and can not be modified any longer. J. has difficulty maintaining good postural alignment throughout the day and becomes uncomfortable when not sitting straight in the wheelchair.

Function also decreases when sitting poorly. J. continues to need a standard tilt-in-space seating system for pressure relief. She also tested a lateral tilt system and determined that this system would be beneficial for improving postural alignment and negating the affects of her scoliosis. Her comfort improved when trying this
system and she did not have to request positioning changes increasing her independence. J. preferred driving a center wheel drive wheelchair rather then her current rear wheel drive system for improved ease to mobilize the wheelchair and get in and out of tight spots. She had less fatigue when driving this system due to less steps involve for turning the wheelchair and accessing sink and computer.

Invacare TDX SP

J. tested the Quickie Rhythm and Jazzy 6000 wheelchair but was dissatisfied with the drive on these chairs. She was most comfortable with the drive on the Invacare wheelchair. The chair was the smoothest for her to drive and provided her with the best maneuverability. She preferred the center wheel system over her current rear wheel drive wheelchair for improved access to her bathroom and her room. She continues to be a safe driver in the center wheel system.

Invacare MPJ +Rehab Joystick and Two TASH Microlite Switches

J. was able to operate the buttons on the hand control and see the display with ease to know what mode she was in. She preferred using the joystick to change her position rather then using a separate switch. She was able to change her speed with the speed dial knob. She occasionally had difficulty changing the modes and turning the chair off so 2 separate TASH microlite switches will be necessary to activate these functions. This will ensure her independence on days that she may have increased weakness due to her MS.

Motion Concepts Lateral Tilt and Standard Tilt-in-Space Seating System

J. frequently requests repositioning of her body in her current tilt-in-space system even though she is able to tilt herself rearward. This movement does not assist with improving trunk alignment and decreasing the effects of her scoliosis. The lateral tilt system provided J. with the ability to adjust the wheelchair to accommodate her scoliosis. She could feel the difference in her body when using this type of system.

Motion Concepts Multi Position Flat Arm Pads with Height Adjustable Armrests

Arm position is important for J. for stability and postural alignment. The wide armpads provide J. with full arm support for increased comfort.

Motion Concepts 70° Swingaway Footrests with Angle Adjustable Footplates.

J. needs good foot support for lower extremity stability and optimal postural alignment of lower legs and feet.

Gel Batteries and Flat Free Tires

Maintenance free batteries are needed for safety and proper care of wheelchair in a long-term care setting. Flat free tires are needed to ensure long-term safety when driving the wheelchair.

Swingaway Joystick Hardware and Tie Down Brackets

The swingaway joystick hardware will assist J. in getting closer to tables, sink and computer for maximum independence during functional activities. The tie down system is necessary to ensure safety while being transported to medical appointments.

Roho Seat Cushion

J. has been using a Roho seat cushion for many years and skin has continued to be maintained in good condition. J. continues to need this cushion for pressure relief.

Use Current AES Back Support System

J.’s back support and lateral trunk supports are in good condition and comfortable for J.. No changes needed to the system at this time.

Right lateral Hip Guide

A new pad is needed to replace the current torn hip guide.

Use Existing Posalink Lateral Knee Supports

The current posalink knee pads are in good condition and can continue to be used for positioning.

Lateral Foot Pads

J. uses lateral walls to control her foot position. The pads are torn and need to be replaced.

Thank you for your assistance in funding the above equipment.


John Doe, PT, ATP

Effect of Passive Range of Motion Exercises on Lower-Extremity Goniometric Measurements of Adults With Cerebral Palsy: A Single-Subject Design

Wednesday, October 19th, 2011

By Sherri L Cadenhead, Irene R McEwen and David M Thompson

SL Cadenhead, PT, MS, PCS, is Early Interventionist, Programs for Infants and Children, Anchorage, Ala. At the time the study was conducted, she was employed at the Northern Oklahoma Resource Center, Enid, Okla

IR McEwen, PT, PhD, is Presbyterian Health Foundation Presidential Professor, Department of Physical Therapy, University of Oklahoma Health Sciences Center, PO Box 26901, Oklahoma City, OK 73190 (USA) ( ).

DM Thompson, PT, MS, is Assistant Professor, Department of Physical Therapy, University of Oklahoma Health Sciences Center

Address correspondence to Dr McEwen

Submitted March 7, 2001; Accepted November 13, 2001

Background and Purpose. People with spastic cerebral palsy often receive passive stretching that is intended to maintain or increase joint passive range of motion (PROM) even though the effectiveness of these exercises has not been definitively demonstrated. The purpose of this study was to determine the effect of PROM exercises on 6 adults with spastic quadriplegia and contractures. Participants. Four men and 2 women ( =31 years of age, range=20–44 years) who lived in an institution for people with mental retardation participated in the study. Methods. The authors used 2 multiple baseline designs. Three participants (group 1) received lower-extremity PROM exercises during phase A; PROM exercises were discontinued during phase B. Three participants (group 2) did not receive PROM exercises during phase A; PROM exercises were initiated during phase B. Data were analyzed using visual analysis and the C statistic. Results. Results varied with the method of analysis; however, phase A and phase B measurements, overall, did not differ for either group. Discussion and Conclusion. This study demonstrated use of a single-subject design to measure the effect of PROM exercises on adults with cerebral palsy. The authors concluded that the PROM exercise protocol did not have an effect on the lower-extremity goniometric measurements of the participants.

Key Words: Cerebral palsy • Contractures • Passive range of motion • Single-subject design

Contractures are among the most common secondary impairments associated with cerebral palsy, particularly for people with the spastic type of cerebral palsy.1 Contracture, as it relates to cerebral palsy, has been defined in several ways, including permanent contraction of a muscle,2 high resistance to passive stretch,2 hypoextensibility,3,4 diminished range of passive stretch,5 and intrinsic muscle shortening that prevents full range of motion.6 Many interrelated factors have been proposed to cause contractures in people with cerebral palsy, including more activation of muscles on one side of a joint than on the other side,4 changes in connective tissue and muscle length,7,8 slow muscle growth,4 and positioning.9 People with spastic cerebral palsy who do not walk and whose voluntary movement is restricted to the extent that they cannot independently move their joints through the full range of motion during daily activities are at particularly high risk for developing a contracture.10

Passive stretching is one physical therapy intervention for the prevention or reduction of contractures associated with cerebral palsy.10,11 In our experience, clinicians frequently advocate a prolonged stretch, with the rationale based in part on a classic study by Tardieu et al.5 Tardieu and colleagues measured the amount of time that the soleus muscles of children with cerebral palsy were elongated beyond a minimum threshold length throughout each day. After 7 months, contractures increased in participants whose soleus muscle was elongated for only 2 hours per day, but these contractures did not increase in participants whose soleus muscle was elongated for at least 6 hours a day.

Casting12 and splinting13,14 are 2 interventions that provide a prolonged stretch and have been shown to be effective in preventing or reducing knee and ankle contractures in children with cerebral palsy. Positioning, such as lying prone, standing in standers,15 and sitting with the hips abducted,16 also can provide a prolonged stretch. The effectiveness of most positioning for maintaining or increasing range of motion of people with cerebral palsy, however, has not been studied.15,17 Researchers have shown that using a chair to provide a 5- to 7-hour adductor stretch per day, along with 1 to 3 therapy sessions per week for “progressive manual stretching,”16(p984) did prevent adductor muscle contractures in children with cerebral palsy.

A practical problem associated with providing a prolonged stretch using splints, casts, or positioning is that adults with severe cerebral palsy often have contractures in many joints and limitations in more than one plane of movement. Hip motion, for example, typically is restricted in abduction, lateral rotation, and extension.11,16 Another problem is that the severity of the contractures can limit positioning options, such as standing. Passive range of motion (PROM) exercises are interventions that are used for contractures of any severity and all limitations of joint PROM. Although some authors have proposed that PROM exercises are ineffective18 (an opinion that is supported by the studies showing prolonged elongation to be necessary5,12–14), other therapists continue to use passive stretching.10,11 In 2 studies, researchers found at least minimal benefits to PROM exercises for young people with cerebral palsy.7,19

Over a 2-year period, McPherson et al7 examined the effects of PROM exercises and positioning on knee flexion contractures of 4 participants between 10 to 18 years of age. During the first year of the study, the participants received PROM exercises 3 times a day at school and twice a week at home. During the second year, PROM exercises at school were discontinued, and participants were positioned in prone and supine standers for 1 hour a day. The PROM exercises continued twice a week at home. The authors compared PROM measurements for periods of treatment (when school was in session) with PROM measurements for periods of nontreatment (Christmas and summer vacations). The participants’ PROM measurements increased during the 2 school semesters of the first year and the fall semester of the second year, and they decreased during 3 of the 4 nontreatment periods. The average increase over the year was 4 to 9 degrees, and the average decrease during nontreatment times was 5 to 10 degrees.

Miedaner and Renander19 studied 13 participants who were 6 to 20 years of age and assigned the participants to 1 of 2 groups. For 5 weeks, one group received PROM exercises 5 consecutive days a week, and the other group received PROM exercises 2 nonconsecutive days a week. For the next 5 weeks, the frequency of exercise was reversed for the 2 groups. Changes in PROM measurements averaged plus or minus 2.5 degrees. Frequency of PROM exercises made no difference in 6 of the 7 lower-extremity measurements. Straight leg raising on the right side was greater under the 5-day-per-week condition than under the twice-a-week condition. As was the case in the study by McPherson et al,7 participants received positioning and bracing in the classroom and PROM exercises at home throughout the study, which makes the contribution of the PROM exercises unclear.

Although research supporting the effectiveness (or ineffectiveness) of PROM exercises is limited, we have observed that PROM exercises are commonly used interventions for adults with cerebral palsy in institutions and community-based programs. These exercises usually are carried out by staff who have been taught by physical therapists to do the exercises during times set aside for exercise or during daily activities (eg, dressing, bathing). Although the performance of PROM exercises often continues for years, we have observed few attempts to determine whether they are effective. A single-subject research design is one method of gathering evidence in clinical settings to determine whether an intervention is effective.20 We used a single-subject research design for this study to examine the effect of PROM exercises on lower-extremity PROM measurements of 6 adults with cerebral palsy.


Six adults (4 men and 2 women; =31 years of age, range=20–44 years) with spastic quadriplegic cerebral palsy participated in the study. See Table 1 for descriptions of the participants. All participants lived in a state-operated residential facility for people diagnosed with mental retardation. A physician and the first author (SLC) selected participants based on 4 criteria: (1) having a legal guardian who could be contacted and who was willing to sign the informed consent form, (2) presence of lower-extremity contractures measuring 20 degrees or greater in at least 3 of the joint motions measured in the study (ie, hip extension, hip abduction, hip lateral rotation, knee extension, and ankle dorsiflexion),13 (3) use of a wheelchair as the primary means of mobility, and (4) current or previous participation in a physical therapy program. Exclusion criteria were: (1) a history of resisting PROM exercises to the extent that full PROM was rarely, if ever, achieved, as judged by the first author, (2) a medical condition that might have prevented the participant from completing the study, (3) a diagnosis of arthritis or other joint disease, (4) lower-extremity orthopedic surgery within 2 years of the beginning of the study, and (5) a windswept hip deformity (limitations of adduction and medial rotation of one hip and limitation of abduction and lateral rotation of the opposite hip21) that prevented positioning for goniometric measurements.

Table 1. Participant Characteristics

We planned the study to be a single-subject, multiple-baseline design with 6 participants, 3 of whom received PROM exercises (group 1) and 3 of whom had not received PROM exercises for at least 6 months before the start of the study (group 2). All participants had previously received PROM exercises and developmental therapy for many years, but PROM exercises had been discontinued for group 2 participants after they demonstrated fairly stable PROM measurements over time, as determined by annual physical therapy examinations. We wanted to know whether the PROM of participants who were receiving PROM exercises would change when the exercises were discontinued and whether the PROM of participants who had not been receiving the exercises would change when exercises were provided.

Table 1 lists characteristics of the 6 participants. All were diagnosed as having mental retardation, but the true abilities of people with severe cerebral palsy and limited communication skills can be difficult to measure. The musculoskeletal status and functional abilities of the 2 groups were similar, but the average age of the group 1 participants was 25 years (range=20–32 years), and the average age of the group 2 participants was 36 years (range=32–44 years). The older age of the group 2 participants probably contributed to the decision to discontinue their PROM exercises, which had occurred before the first author started working at the institution. These 6 participants were selected for the study because they were the first people who met the inclusion criteria and whose legal guardians provided us with informed consent.


The study consisted of 2 multiple-baseline designs, each with 3 participants.22 During phase A, group 1 participants, who had been receiving PROM exercises 3 times per week, continued to receive PROM exercises. During phase B, PROM exercises were discontinued. Group 2 participants received no PROM exercises during phase A, and PROM exercises were provided during phase B.

As is customary in multiple-baseline designs, the duration of each phase for each participant was individualized, and the initiation of phase B was staggered across the participants as each participant’s PROM measurements became stable.22 For the majority of the joints measured, PROM measurements were considered stable when they were within 5 degrees of each other23 over a period of at least 3 out of 4 weeks. Stability, or a stable trend (increasing or decreasing measurements at a constant rate of change) over a period of 3 out of 4 weeks, was the criterion for discontinuing PROM exercises for group 1 participants or for beginning PROM exercises for group 2 participants. All participants were measured each week for 16 consecutive weeks. Phase A measurements for group 1 participants were established after 5 weeks for participant 1A, after 8 weeks for participant 1B, and after 11 weeks for participant 1C. For group 2 participants, phase A measurements were established after 4 weeks for participant 2A, after 8 weeks for participant 2B, and after 11 weeks for participant 2C.


The independent variable was a PROM exercise program for the joint motions of hip extension, hip abduction, hip lateral rotation, knee extension, and ankle dorsiflexion. The first author instructed physical therapy aides in the PROM exercise protocol. Instruction included verbal explanation, demonstration, observation of the aides performing each exercise, feedback on their performance, and written instructions with pictures illustrating how to perform each exercise. The exercises were based on PROM exercises published by Bezner24 and Kisner and Colby.25 For each of the participants, the investigator monitored one exercise session a week throughout the study to ensure that the physical therapy aides adhered to the protocol.

The protocol was based on 2 studies in which the effectiveness of PROM exercise for young people with cerebral palsy was studied.7,19 In both studies, the PROM exercises consisted of moving an extremity passively to the end of the PROM and holding this position for 20 to 60 seconds, then repeating this stretch 5 times. Researchers studying people with and without neuromusculoskeletal impairments have found that one 30-second stretch 5 days a week is as effective in increasing hamstring muscle length as one 60-second stretch or three 30- or 60-second stretches.26,27 Based on our experience with people with cerebral palsy, however, we believe that more than one repetition is beneficial because resistance to passive stretch seems to decrease with repetition.

The aides performed 5 repetitions of each passive joint motion, holding the position at the end of the range for 20 seconds during each repetition. They were instructed to move the joint only to the point of resistance and to avoid forcing the movement. They also were given instructions for obtaining as much motion as possible, such as moving slowly, providing a gentle continuous stretch, avoiding pressure on the balls of the feet or palms of the hand, and bending an adjacent joint if movement was difficult to initiate.

The aides could do the 5 exercises in any order that they chose. Participants were placed in a supine position for all exercises except hip extension. For the hip extension exercise, participants were positioned prone with their hips at the edge of the table. The aides’ hand placements were done as illustrated in Bezner.24

The PROM exercise sessions were carried out 3 times per week. Each session lasted for approximately 30 to 45 minutes, including time for transferring, positioning, and talking with the participant. In the studies26,27 of people without neuromusculoskeletal impairments, the researchers did not examine frequencies other than 5 days per week. They provided no rationale for using this frequency. We selected a frequency of 3 days per week because, in our experience, it is a frequency often used for adults with cerebral palsy living in institutions and because Miedaner and Renander19 found that PROM did not differ when their participants received PROM exercises 2 times a week or 5 times a week.


Our study’s dependent variables were bilateral goniometric measurements of hip extension, hip abduction, hip lateral rotation, and ankle dorsiflexion as well as 2 measurements of knee extension: one with the hip flexed and the other with the hip extended. Measurements were taken each week using a 30.48-cm (12-in) plastic goniometer with a 360-degree scale. Although the reliability of goniometry for measuring joint limitations due to contractures has been questioned,28,29 investigators often have used a goniometer to measure the joint PROM of people with cerebral palsy.7,19 To promote consistency in measurements, the 16 measurement sessions for each participant were done on the same day of the week and at the same time of day, with the participant lying on a firm, vinyl-covered, high-low mat table. Semipermanent marks were made on each participant’s bony landmarks with a laundry marker to identify the goniometer’s fulcrum, stationary arm, and measurement arm positions. Color photographs of the measurement positions and specific written instructions for the 6 joint motions were available for the aides and therapists to review throughout the study.

When measuring each joint motion, the first author, designated as therapist 1, moved the extremity passively through the full available PROM for 3 repetitions. A slow 30-second stretch was applied on the third repetition to “differentiate a reflex or active muscle contraction from the structural limitation of the muscle, tendon, or joint capsule.”29(p661) This procedure was intended to minimize resistance to passive stretch and identify the end of the PROM. The joint PROM was measured at the end of the 30-second stretch by an occupational therapist (therapist 2). Although having someone other than the principal investigator move the limb through the PROM (to control for potential bias) would be the preferred method, another person with the necessary skill was not available for the number of measurement sessions required. To help control for bias, therapist 2 was not informed of the participants’ group assignments and their progress within and between the phases of the study.

The testing sequence was consistent for every measurement session,30 and the procedures for positioning and hand placement were standardized for each joint motion.31 First, each participant’s right lower extremity was measured in the following order: (1) knee extension in the supine position with the hip extended29; (2) knee extension in the supine position with the hip flexed to 90 degrees, as indicated by a goniometer that was fixed at 90 degrees and positioned on the mat table at the level of the greater trochanter19; (3) ankle dorsiflexion in the supine position with the knee extended and the calcaneus in as neutral a position as possible in an attempt to distinguish between ankle and forefoot motion29; (4) hip abduction in the supine position with the hip extended and the lower leg positioned off of the end of the table32; (5) hip lateral rotation in the supine position with the lower leg positioned off of the end of the table28; and (6) hip extension in the prone position with the hips at the edge of the table, the pelvis level, and the knee flexed.33 While the participant was positioned prone, left hip extension was measured. Then, the remaining left lower-extremity joints were measured in the same order as the joints of the right lower extremity. Because all of the participants had knee flexion contractures and because of the importance of knee extension with hip flexion for wheelchair seating, knee extension was measured with the hip extended as far as possible and with the hip flexed to 90 degrees. Flexing the hip to 90 degrees also was intended to control any effects on knee PROM if hip extension changed over the course of the study.

To determine interrater reliability, approximately 18% of the measurements, including 2 or 3 measurement sessions per participant, were repeated independently by another physical therapist (therapist 3) throughout the duration of the study. Therapist 3 participated only in the reliability study and did not know the participants’ group assignments and progress. Therapist 3 followed the measurement protocol while therapist 1 (the first author) measured the joint PROM. Therapist 1 used a goniometer that was masked on one side with paper to prevent her from seeing the result until after therapist 2 (the occupational therapist) had recorded each measurement.34 Before the study was initiated, the 3 therapists practiced the measurement, positioning, and stretching techniques until they achieved agreement within 5 degrees per joint measurement. We chose to determine interrater reliability rather than intrarater reliability because (1) we were concerned that memory would affect 2 trials by one rater separated by a short interval and (2) if interrater agreement was acceptable, intrarater agreement also was likely to be acceptable.

Reliability was represented by an intraclass correlation coefficient (ICC), model 3,1.22,35 Table 2 shows that coefficients were between .785 for right hip lateral rotation and .988 for right knee extension with the hip flexed to 90 degrees. w this table:


The goniometric measurements collected over the course of the study were recorded on 12 graphs for each participant (one graph for each of the 6 right and left joint motions), for a total of 72 graphs. The graphs were oriented to show an increase in PROM when the data points went in an upward direction and a decrease in PROM when they went in a downward direction.

We first analyzed the graphed data through visual analysis, a traditional method of interpreting single-subject research,36 to determine whether PROM improved, decreased, or did not change across the 2 phases. Through visual analysis, investigators look grossly at level, trend, variability, and slope of the graphed data.37 We used trend data more than level data because changes in level (eg, rapid change in PROM) were not expected and were due possibly to measurement error. We also used visual analysis of trends in conjunction with phase values and changes in slope between phases to determine trend change scores (eg, a joint motion with a low trend phase value [3 or less] and a low slope [approximately 1.0 to 1.05] indicated no change). We disregarded outlier data points (defined as a data point that was 20 degrees greater than or less than the data points immediately before and after it) if at least 5 other data points were available in that phase, and we considered data that remained consistently variable across phases to demonstrate no change.

Investigators have noted that visual analysis alone may lead to inconsistent results.38,39 For this reason and because small treatment effects were expected,37 we also used the C statistic to further analyze the data.40,41

Nourbakhsh and Ottenbacher42 used 3 statistical methods for single-subject data—the split-middle method of trend estimation, the two-standard deviation bandwidth method, and the C statistic—to analyze the same 42 graphs. They found somewhat different results using each method and concluded that researchers should use several approaches to analyze single-subject data, one of which should be visual analysis. We chose the C statistic as the other method because many of the graphs showed a visually obvious trend, which made the two–standard deviation bandwidth method inappropriate,42 and because the split-middle method of trend estimation often is inconsistent with visual analysis.

With the C statistic, phase A data are analyzed first to determine whether a statistically significant trend exists. Statistical significance is determined by dividing C by its standard error, which gives a z value that can be interpreted using the normal probability table for z scores.40,42 If a trend is not found, the phase B data are appended to the phase A data, and the combined data are reanalyzed using the same procedure. If a trend is found in the phase A data, a less powerful alternative procedure can be used to construct separate data series from phase A and phase B data and to compare them. A significant z score indicates that the trend in phase A and phase B are different.40 We used a 1-tailed test with an alpha of .05 (z 1.645). The unidirectional hypothesis was that PROM would be greater during the phase in which PROM exercises were provided.

Visual analysis of the data of participant 1A indicated no change in PROM between phase A and phase B for 10 of the 12 joints measured. The rate of increase in left hip extension decreased during phase B and a downward trend occurred in right ankle dorsiflexion during phase B. Both observations were supported by the z values. The z values also indicated a difference between phases in bilateral hip lateral rotation and knee extension with the hip flexed 90 degrees. Visual analysis indicated that the reason for the discrepancy was probably the increasing trend during the relatively short phase A, which leveled off during phase B.

Visual analysis of participant 1B’s data identified no change in 7 of the 12 measurements. Right and left hip lateral rotation showed a downward trend in phase B and ankle dorsiflexion decreased bilaterally during phase B. Left hip abduction increased during phase B. The z values supported a difference in these 5 measurements. The z values also indicated a difference in right and left knee extension with the hip flexed 90 degrees, which visual analysis had not revealed. We examined the graphs again to try to determine the reason for the discrepancy and saw that PROM increased during phase B (also indicated by the means), but not enough to say with any confidence that a difference existed. The z values could not support a difference because we used a 1-tailed test, and the direction of any difference was in the opposite direction.

Visual analysis of participant 1C’s data showed no difference in PROM between phases for 9 of the 12 measurements. During phase B, right hip lateral rotation and right knee extension with the hip flexed 90 degrees decreased. This finding was supported by the z values. Visual analysis indicated that left hip abduction increased during phase B. The visual analysis did not support the z values, which indicated a difference in right hip extension and left knee extension with the hip flexed 90 degrees. Reinspection of the graphs again indicated no change, which was supported by the mean PROM during the 2 phases. The long baseline with an increasing trend in the baseline data may have affected the C statistic results.


Table 4 shows the means, standard deviations, visual analysis results, and z values for the 36 graphs for group 2. Group 2 participants did not receive PROM exercises during phase A and PROM exercises were provided during phase B.

Table 4. Goniometric Data (in Degrees) for Group 2 Participants Who Did Not Receive Passive Range of Motion (PROM) Exercises During Phase A and Received PROM Exercises During Phase B

Visual analysis of the data for participant 2A showed no change in 7 of the 12 PROM measurements. Visual analysis indicated an increase in 2 measurements during phase B: left knee extension with the hip extended and left knee extension with the hip flexed 90 degrees. The z values supported these 2 observations and indicated no other increases in PROM during phase B. Visual analysis indicated a decrease in 3 measurements when PROM exercises were provided during phase B: right hip extension, right knee extension with the hip extended, and right ankle dorsiflexion.

Visual analysis of participant 2B’s data indicated no change in 8 of the 12 measurements. Visual analysis showed a negative change in 4 measurements during phase B: bilateral hip lateral rotation and dorsiflexion. No positive changes were identified with visual analysis or the z values.

Visual analysis of the data of participant 2C indicated no change in 8 of the 12 PROM measurements. A negative change was observed during phase B in 3 PROM measurements: bilateral hip lateral rotation and right ankle dorsiflexion. Visual analysis and the z value indicated an increase in right hip abduction during phase B.

In summary, visual analysis of the grouped data for the subjects in group 1 showed no change in 28 of 36 joints when PROM exercises were discontinued. Visual analysis showed decreased PROM in 8 joints, results that the z values supported. Visual analysis also showed an increase in PROM for 2 of the 36 joints after PROM exercises were discontinued. The z values indicated a decrease in 4 joint PROM measurements when PROM exercises were discontinued, which was not supported by visual analysis.

Visual analysis of the data of all 3 subjects in group 2 showed no change in PROM for 23 of 36 joints when PROM exercises were provided. Visual analysis and the z values indicated an increase in PROM in 3 joints when PROM exercises were provided during phase B. Visual analysis indicated a decrease in 10 measurements during phase B.

For both groups of participants, our results showed no consistent differences in lower-extremity PROM measurements when the participants received and did not receive PROM exercises. Most of the participants demonstrated a gradual increase in PROM in phase A and showed little change in motion during phase B, regardless of whether PROM exercises were discontinued or provided during phase B. As a result of the study, PROM exercises were discontinued for all participants.

The gradual increase in PROM during phase A appeared to be the result of the participants’ increasing cooperation with the person taking the PROM measurements over the first few weeks of the study. Although an exclusion criterion was resistance to PROM to an extent that joint range could not be achieved, the participants did appear to guard against full PROM initially. The participants also demonstrated week-to-week variability in measurements that we believe were unlikely to be related to real change in joint PROM.

We are not aware of research that has examined consistency of goniometric measurements of adults with spastic quadriplegic cerebral palsy; however, Harris and colleagues43 found wide daily variations when measuring a child with spastic quadriplegia, and they concluded that a change of 10 to 15 degrees may not represent real change. We contend that our interrater reliability estimates were excellent to good; however, we assessed reliability by having 2 therapists measure the participants on the same day, one immediately after the other. Day-to-day variation in participants would not have been affected by—or detected by—our method. Future research to examine test-retest reliability of goniometric measurements of adults with spastic quadriplegia and cognitive impairments, with time between measurements, could be useful.

Despite the variability of our measurements, we showed that, for the 6 adults with cerebral palsy, PROM exercises did not appear to generally affect lower-extremity goniometric measurements over a 16-week period of time. A limitation of our study was that all participants did not receive the same amount of PROM exercises. The staggered phase A and 16-week available time frame meant that participants received from 5 to 12 weeks of PROM exercises. The results, however, are consistent with the views held by some authors18,44 that passive exercise is not effective in the management of contractures associated with cerebral palsy. The results are not consistent with the results of the studies by McPherson et al7 and Miedaner and Renander,19 who found modest PROM increases following PROM intervention.

One reason for the inconsistency may be the age of the participants. Our participants were between 20 and 44 years of age, and their contractures could have been less responsive to change than participants in the other studies who were between 6 and 20 years of age. Another difference in the studies is that their participants received positioning and other co-interventions, which our participants did not receive. These co-interventions, rather than the PROM exercises, could have been responsible for the change.

The studies also differed in the number of participants, the length of the intervention, the joints investigated, and the research design. McPherson et al7 used a group design to study knee extension of 4 participants over a 2-year period. Miedaner and Renander19 also used a group design and studied the hip, knee, and ankle PROM of 13 participants over 10 weeks. Our study was similar to these previous studies in the limited number of participants, but our use of a single-subject design enabled us to analyze the effects of intervention for each participant, which the group designs do not permit. Some of the participants in the previous studies may not have benefited from the intervention, but the analyses of group data would have obscured the individual effects.

The amount of PROM exercise also may have contributed to lack of changes in the measurements. Although the PROM protocol was based on the literature related to people with cerebral palsy,7,19 research with people without neuromusculoskeletal deficits indicate that stretching for one 30-second stretch 5 times per week is effective.26,27 Although this amount cannot be generalized to people with neuromusculoskeletal impairments, it may be worth investigating. Another consideration is the length of the intervention. Our 16-week study may not have been long enough to show an effect of PROM exercises or an effect of discontinuing them.

The results of our study cannot necessarily be generalized to other adults with cerebral palsy, particularly those with characteristics that differ from those of our participants. The external validity of single-subject research is demonstrated by replication,22 and our design and methods lend themselves well to the clinical setting and could be used by other clinicians to determine whether PROM exercise is effective for individual clients. Replication of the study with other people with similar characteristics also would broaden its applicability.22 For future studies, a larger number of data points and a more stable baseline could improve the accuracy of the analyses.

Measurement and treatment of contractures will continue to be important for adults with cerebral palsy to address potential deterioration, overuse syndromes, and joint deterioration.1 Physical therapy programs that focus only on PROM, however, should be reconsidered because both the clinical usefulness and social validity45 of this intervention are questionable. Social validity is a term used in applied behavior analysis, from which single-subject research developed. It refers to the social importance of treatment goals and procedures, and the person’s satisfaction with them. Intervention, we believe, must go beyond the person’s secondary impairments to address functional limitations and ability to fulfill life roles.46 Future research, in addition to attempting to answer continuing questions about the effectiveness of various techniques for increasing PROM measurements, needs to address questions about relationships between joint PROM and functional capabilities. Even if a technique is shown to increase PROM, we need to know whether the increase affects the ability of an adult with cerebral palsy to function or makes an important difference in the ease of caregiving.
All authors provided concept/research design and data analysis. Ms Cadenhead and Dr McEwen provided writing. Ms Cadenhead provided data collection and project management, and Dr McEwen provided fund procurement. The authors thank the occupational therapist who helped with data collection, the physical therapist who participated in the interrater reliability study, and the participants’ physician who assisted with the study.

This study was conducted in partial fulfillment of the requirements for Ms Cadenhead’s postprofessional Master of Science degree from the University of Oklahoma Health Sciences Center. The study was approved by the University of Oklahoma Health Sciences Center Institutional Review Board and by the Human Rights Committee of the Northern Oklahoma Resource Center.

The study was partially supported by Preparation of Related Services Personnel grants H029F00056 and H029F30020 from the US Department of Education, Office of Special Education and Rehabilitative Services. This article, however, does not necessarily reflect the policy of that office, and official endorsement should not be inferred.

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Medicare Power Mobility Documentation Requirements

Wednesday, October 19th, 2011

July 10, 2008
Power Mobility Documentation Requirements

A review of power mobility claims and ADMC requests submitted to Jurisdiction C shows continued uncertainty regarding the various assessment and evaluation documentation requirements. The following article reviews this information and includes a reference chart indicating the assessment and exam requirements for the various levels of power mobility.

Face-to-Face Exam

What is It?

The face-to-face examination is a statutory requirement for all power mobility devices (PMD). This exam consists of two separate elements, an in-person visit to the physician for the purpose of requesting a PMD, and a comprehensive medical examination.

Who Can Perform It?

The treating physician must conduct the in-person visit. The comprehensive medical evaluation may be performed by the physician or may be referred to a licensed/certified medical professional (LCMP), such as a physical therapist or occupational therapist, who has experience and training in mobility evaluations to perform part of the exam. If the treating physician has referred the medical examination to a LCMP, the physician must review the findings after receiving the LCMP’s report. In addition the physician must document their acceptance of this report in writing and sign and date the entry.

REMINDER: If the report of an LCMP examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier.

How Should the Findings be Reported?

The in-person element of the face-to-face exam should be documented in a detailed narrative note in the physician’s chart in the format that they use for other entries and clearly indicate that a major reason for the visit was a mobility examination. The comprehensive medical examination may be documented either:

In the physician’s narrative record, if they performed the entire exam; or,

By including the report of the LCMP exam in the office record if the exam was referred.

A supplier generated form must not be used to document either the treating physician’s or LCMP’s exam since a supplier generated form is not a considered to be a part of the medical record.

REMINDER: The supplier must receive a written report of the face-to-face exam within 45 days after its completion and prior to delivery of the wheelchair.

Specialty Exam

What is It?

The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory is needed to address the patient’s mobility limitation.

A specialty exam is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3, 4 or 5 PWC, or a push-rim activated power assist device.

Who Can Perform It?

The specialty exam must be performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations. The person performing this exam may, but is not required to be, a RESNA-certified ATP.

REMINDER: The PT, OT, or physician performing the specialty exam may have no financial relationship with the supplier.

How Should the Findings be Reported?

The policy does not prescribe a specific format for reporting the specialty exam findings. However, the report should be in the office or facility’s usual medical record form; it should not be on a supplier-generated form.

Home Assessment

What Is It?

All levels of PMD require that an onsite evaluation of the patient’s home be performed prior to or at the time of delivery. The person conducting this assessment should verify and document, in a written report, that the patient’s typical environment supports the use of a PMD.

Who Can Perform It?

The home assessment can be performed by the supplier (or supplier’s employee) or a practitioner (physician, physician’s employee or LCMP, etc.).

How Should the Findings be Reported?

The policy does not specify a particular format or form to use. The policy, however, does state that the assessments and measurements should include physical layout of the home, doorway width, doorway thresholds and surfaces the device will have to move over.

ATS/ATP In-person Appraisal

What Is It?

As of April 1, 2008, suppliers providing certain wheelchairs as described in the PMD LCD must employ a RESNA credentialed professional and this person must have direct in-person involvement in the wheelchair selection process. For an in-depth review of this requirement, please refer to the recently published article, Power Mobility Devices, FAQ – ATS/ATP Requirements.

Who Can Perform It?

This process must be performed by either a RESNA-certified Assistive Technology Supplier (ATS) or Assistive Technology Practitioner (ATP) who specializes in wheelchairs and is employed by the supplier.

NOTE: The requirement for the supplier to employ a RESNA-certified professional and for this person to have direct, in-person involvement in the wheelchair selection process is not waived if the specialty exam is performed by an ATP. The person performing the specialty exam cannot work for the supplier and the person involved in the ATS/ATP in-person appraisal must have a financial relationship with the supplier. Therefore, one individual cannot meet both requirements.

How Should the Findings be Reported?

There must be evidence in the supplier’s file of direct in-person interaction with the patient by the ATS/ATP in the wheelchair selection process. The documentation must be complete and detailed enough so a third party would be able to understand the nature of the ATS/ATP involvement and to show that the standard was met. Just “signing off” on a form completed by another individual would not adequately document direct, in-person involvement. Also, merely signing a statement such as, “I am a RESNA-certified professional specializing in wheelchairs and had direct, in-person involvement in the wheelchair selection for this patient” does not sufficiently verify that this policy requirement was met. Finally, a home assessment completed by a supplier-employed ATS/ATP would not meet the requirement unless the documentation showed how the ATS/ATP applied the assessments and measurements to the wheelchair selection process.


PMD Group HCPCS Code Range Face-to-Face Exam Specialty Exam Home Evaluation ATS/ATP In-person Appraisal

Group 1 POV K0800-K0802 Yes No Yes No

Group 2 POV K0806-K0808 Yes No Yes No

Group 1 PWC K0813-K0816 Yes No Yes No

Group 2 PWC – NPO K0820-K0829 Yes No Yes No

Group 2 PWC – SPO K0835-K0840 Yes Yes Yes Yes

Group 2 PWC – MPO K0841-K0843 Yes Yes Yes Yes

Group 3 PWC – NPO K0848-K0855 Yes Yes Yes Yes

Group 3 PWC – SPO K0856-K0860 Yes Yes Yes Yes

Group 3 PWC – MPO K0861-K0864 Yes Yes Yes Yes

Group 4 PWC K0868-K0886 Yes Yes Yes Yes

Group 5 PWC K0890-K0891 Yes Yes Yes Yes

Abbreviation Key PMD = Power Mobility Device

POV = Power Operated


PWC = Power Wheelchair MPO = Multiple Power Options

NPO = No Power Options

SPO = Single Power Option

Refer to the Power Mobility Devices LCD for additional information on coverage and documentation requirements.

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Medicare Physician Guide For Power Wheelchair Documentation

Wednesday, October 19th, 2011

Coverage Criteria and Documentation Requirements for Power Mobility Devices (Power Wheelchairs and Scooters) National Coverage Determination (NCD) for Power Mobility Devices (PMD)

Power Mobility Devices include power wheelchairs and scooters/power operated vehicles (POV). If you are considering prescribing a Power Mobility Device please review the following information as it will assist you in understanding how these changes have affected the prescription and funding process with Medicare. Medicare has modernized the policy and replaced the “Bed or Chair Confined” requirement with consideration now given to the beneficiary’s ability to safely and in a reasonable time frame participate in one or more Mobility Related Activities of Daily Living


MRADLs: Dressing, grooming, toileting, bathing and eating (including Assisted Living Facilities) in customary locations within the home

A face-to-face examination of your patient is required prior to prescribing a PMD.

As a prescribing physician of a PMD you are entitled to a new add-on payment for conducting the face-to-face examination and for preparing and sending the required documentation to the PMD equipment supplier. The new add-on code is G0372 and will be paid at a rate equal to the physician fee schedule relative values established for a level I office visit for an established patient (CPT Code 99211).

Coverage Criteria

A face-to-face examination of your patient is required prior to prescribing a PMD.

The 9 questions listed below are the method for examination and should be used to determine the appropriate Mobility Assistive Equipment (cane, walker, manual wheelchair, POV/scooter and power wheelchair). This information must be located in the patient’s medical record that includes your progress notes, hospital notes, home health records and/or through the face-to-face examination of your patient.

1. Does the beneficiary have a limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home? If so, document your patient’s limitation(s) that prevent his/her ability to be safely mobile in his/her home.

2. Are there any other conditions that limit the beneficiary’s ability to participate in MRADLs at home (for example, any cognitive impairment)? If the reason your patient is not safely mobile in his/her home is due to a cognitive impairment please document the impairment. If the reason is not due to a cognitive impairment proceed to question 4.

3. If these other limitations exist, is there a way to compensate for this limitation? If so, document how the limitation can be compensated for – such as an around the clock caregiver, medication, or therapy. If the limitation (question 2) cannot be compensated for through any other means, please note this in the patient’s file.

4. Does the beneficiary or caregiver demonstrate the capability and willingness to consistently operate a Power Mobility Device safely?

5. Can the functional mobility deficit be resolved with a cane or walker? Can your patient safely and within a reasonable time frame use a cane or walker to participate in MRADLs? If not, please document the reason why and the results of cane and walker trials (if applicable)?

6. Does the beneficiary’s living environment support the use of wheelchairs including scooters/power operated vehicles (POVs)? The PMD supplier will perform a home assessment to determine that the beneficiary’s living environment is suitable for a PMD. A copy of this home assessment will be kept in the PMD supplier patient’s file.

7. Can the patient’s mobility limitation be resolved with a manual wheelchair? Please consider the patient’s upper extremity function. Does the patient have the strength, range of motion (ROM) and endurance to safely propel a manual wheelchair all day, every day (and in a reasonable time frame) to participate in MRADLs?

8. Can the patient’s mobility limitation be resolved with a POV/scooter? Please consider the following if prescribing a scooter – the patient’s trunk stability and upper extremity function (see above) to safely operate the scooter’s tiller on a daily basis to participate in MRADLs, the need for safe transfers, positioning and pressure relief, dexterity in his/her hands to operate the scooter controls. Also, the PMD supplier will determine through a home assessment what is the appropriate PMD (i.e. scooter/POV, power wheelchair) for the patient to use in his/her home.

9. Does the patient require the additional features provided by a power wheelchair to safely participate in MRADLs within a reasonable time frame in his/her home?
Documentation Requirements

Medicare requires the above information be supported by the patient’s medical record.


The medical record includes your progress notes, chart notes, hospital records, home health records and/or through a physical/occupational wheelchair evaluation. Once you complete the face-to-face examination with your patient and have determined that a PMD is appropriate you may write a prescription for a PMD. If this power wheelchair is being prescribed for regular use this must be noted in thepatient’s chart.

The patient’s medical record must support the prescription for the device ordered.

Useful Life of the PMD – The “useful life” of Durable Medical Equipment (PMDs are in this category) is considered no less than 5 years beginning with the date of delivery. If you prescribe a PMD please consider the patient’s usage and his/her prognosis for at least the next 5 years. Considerations include the patient’s condition (foreseen changes in his/her medical condition – i.e., a progressive condition such as MS) and the patient’s current weight along with history of weight gain and predicted weight gain (if applicable).

For additional information regarding Power Mobility Devices please contact the equipment supplier or go to medicare physician resource guide 2-color – 05/06

Prescription Requirements

All Power Mobility Devices require a written prescription prior to delivery. The equipment supplier is required by Medicare to have the written prescription, plus proof you have considered the 9 questions listed on the previous page in your files, prior to delivering the Power Mobility Device.

The written prescription must contain the following:

1. Beneficiary’s name

2. Description of item that is ordered. This may be general – e.g. “power wheelchair”- or may be more detailed.

3. Date of the face-to-face examination

4. Pertinent diagnosis/conditions that relate to the need for the Power Mobility Device

5. Length of need

6. Physician’s signature

7. Date of physician’s signature

Please forward the detailed written prescription, along with supporting documentation to the 9 questions, to the equipment supplier as soon as possible to ensure that your patient receives the prescribed equipment in a timely manner. The supplier must receive the written prescription and supporting documentation for the Power Mobility Device within 45 days from the date of the face-to-face examination (See following exception).

If all questions are not supported by the medical record history and cannot be addressed through the face-to-face examination of the patient you may prescribe a physical/occupational therapist wheelchair evaluation to address or support the remaining questions. (In the event you refer your patient to a PT/OT for a wheelchair evaluation, you must obtain a copy of the written evaluation from the therapist and indicate concurrence or disagreement with the assessment. Please co-sign the assessment and submit a copy of the assessment with your written prescription to the PMD supplier within 45 days of the date when you co-signed the therapist evaluation.)