Posts Tagged ‘active american’

ADA and More: Limitations of ADA Law With Respect to the Home Environment

Wednesday, October 19th, 2011

By Adam Horton,
Home Access Division Manager
Active American Mobility

The American’s with Disabilities Act (ADA) was passed July 26, 1991. It was created to prevent discrimination against individuals or groups that have disabilities, either mental or physical. While the ADA was passed to prevent discrimination against individuals in the workplace, public settings, buildings, restaurants, etc., it did not cover anything in the home environment. There are, however, guidelines that are put in place that in the event that a home is being built to ADA guidelines. The problem with this is that it is a mere guideline and not a requirement that can be enforced by code specifically for ADA.

The ADA guideline for a finished door opening is 32”. Most doors in a home are 24”-30”. Exterior doors do have to be wider with one exterior door a minimum of 36”. Other doors in the home are sometimes wide enough, but this is typically the master bedroom and master bathroom doors. A typical hallway is 36” wide, but should be 48” wide to meet ADA requirements. Also, most homes come with a concrete entry walk that joins to a porch with a step up to the porch and also a step into the home. ADA requirements call for a minimum of one no-step entrance into a home for ease of access for mobility equipment. Light switches and thermostats should be a minimum of 48”-54” from the floor and 40” if they are over a counter top. The list of changes goes on and on. The problem with all of this is none of it is required in a typical home setting. It is recommended but not required.

Most home builders will make the changes to a home to meet ADA standards, but it all comes at a cost. Builders will charge a fee most of the time they deviate from the original plan. However, these changes don’t cost much money at all, and if managed properly will only make the home more accessible and accommodating living area.

On a positive note, one organization is making a mark in becoming the “ADA” of the home environment. Accessible Home Improvement of America™ is a new organization that addresses the gaps for home owners that ADA leaves behind. AHIA™ consists of a nationwide network of independently owned and operated , certified providers and contractors dedicated to providing accessible home modifications and related services.

AHIA™ also offers the CEAC (Certified Environmental Access Consultant) credential. This credential brings professionalism and diversity to current businesses. The CEAC™ credential certifies that the consultant is a specialist in independent living strategies, universal design, barrier free access and design, assistive technology, retrofitting, home modifications, and medical remodeling.

Active American will be CEAC certified in the coming months and we look forward to supporting AHIA™

For more information contact Active American Home Access and Construction.


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
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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.
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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.
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Controlled experimental study of turneys on a calcium-insufficient diet.
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Experimental study of healthy males. Level III.
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Experimental controlled study comparing two groups of paraplegic
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RESNA Position on the Application ofWheelchair Standing Devices 14
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Early implementation program of weight bearing for children with
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children. Level V.
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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)

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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Custom Molded Wheelchair Seating: No Need to Fear

Wednesday, October 19th, 2011

by Jeff McDaniel, ATP

Intimidation is the word that comes to mind for many RTS’s when creating a molded seating system. After all, there is little room for error, and modifications after the seating system has been created are usually not possible. And then there is the labor, time, effort, and skill. But we have chosen our career path to help our clients, not to choose the path of least resistance. Even though creating a mold may not be easy, it is rewarding and all of the work is well worth the result when the final product is appropriate.

The first step in creating a molded seating system is knowing when it is needed. It is my opinion that custom molds are under utilized in our industry, probably due to the aforementioned obstacles. However, a custom mold can address numerous issues not attainable via manufactured backs and cushions. A custom mold can:

• Evenly distribute pressure for skin protection
• Relieve pressure points via soft spots
• Correct postural deformities more effectively than standard seating
• Increase function via proper positioning
• Prevent sliding out of the seating system by wedging or troughing
• Improve vision field by accommodating kyphosis
• Improve head control by balancing the torso and bringing the head to midline

In order to create an effective seating system, there are a few tools that are necessary but more importantly, it is critical that the mold be created with the input of an occupational or physical therapist. A knowledgeable therapist not only brings an extra set of eyes but the knowledge necessary to create a functional and appropriate system. Also, an involved family member or caregiver greatly increases the probability of a positive outcome.

First of all, it is critical that a mat exam be performed. This is necessary to ascertain range of motion, flexibility, respiratory function, reflexes, and muscle tone. This is probably the most critical part of the formula as it is the precursor of the mold itself. Once this has been completed, it is time to create the mold. But first, let’s go through the necessary tools.

• Simulator – A frame with a seat and back bag filled with polystyrene beads. This will allow you to create a “simulation” of the mold by pulling a vacuum on the bags resulting in a firm but malleable surface.
• Digitizer – Captures a digital image of the finished simulation and is then emailed to the manufacturer to create the molded seat and back.
• Pressure Mapping System – A digital pad placed under the patient’s bottom and back to isolate pressure areas, which can then be addressed while capturing the mold.
• Pulse Oximeter – Used to monitor respiratory function while creating the mold
• Tape measurer – Used to take measurements of the overall size of the mold in order to configure the size of the wheelchair to accommodate the system.
• Camera – Used for funding and verification of the before and after.

Once you have completed the mat exam, you now know your goals. Are you correcting or accommodating? Are there any pressure concerns such as a history of pressure ulcers? Are there any reflexes present such as hip extension tone? All of these issues will need to be addressed. Common knowledge states to start with the seat cushion but I frequently will start at the seat, complete the back, then finalize the seat. I find that I get a better outcome as molding the back frequently makes changes in the position of the client’s pelvis. If you are correcting an obliquity, it is important to “build up” one side of the seat simulator bag to level the pelvis. Just keep in mind that the more correction there is at the pelvis usually translates into more pressure and/or correction of the back. If accommodating the pelvis, try and build up or trough out the seat simulator enough to bring the client’s head to a midline position. When molding the back, I first fill in the posterior portion of the bag by standing behind the simulator and pushing the beads into the client’s back. This “fills in” the gaps. I then pull the laterals into a supportive position. Just remember not to over do it. A mold does not typically breath very well and can be very hot. Since perspiration is not desired, I frequently will create a “3 point” system by applying pressure at the apex of the convexity and above and below the concavity of the scoliosis. Just remember that less is more. Try to make the system as non-restrictive as possible. If this is not avoidable, holes can be drilled into the final mold to allow air circulation.

Now before the patient is taken out of the system let’s do some checks.

1. Is the client’s head midline?
2. Does the system restrict or facilitate functional movements?
3. Does the system protect and/or reduce pressure in concerned areas?
4. Has respiratory function been compromised?
5. Has range of motion been limited or is range of motion at maximum limits?
6. Has field of vision been improved or limited?

These are some general checks I use but there may be other concerns, just make sure that the end result matches your goal for the system.

At this point I measure the width from left to right lateral on the seat and the back as the system can be altered when transferring the client out of the system. It is also important indicate or mark the desired height of the back, the seat depth and the seat to back angle. Once the client has been transferred out, you can either cast or digitize the simulator, depending on what brand of system being used.

Now all of this process is all for nothing if funding hasn’t been procured. Medicare, Medicaid, and most private insurances will readily fund this type of system. The criteria is fairly simple. Medicare and Medicaid criteria state that a custom seating system is medically necessary when a manufactured seat or back will not correct or accommodate the client’s positioning needs. Additionally, I think it is important to indicate the patient’s current positioning, postural deformities, and skin integrity. These criteria, along with a PT/OT seating assessment will typically provide the justification necessary for funding. Photographs are also a great idea as “a picture is worth a thousand words”, so be sure and take before and after pictures. Some, but not all funding sources also allow billing for time and labor, not just the seating system itself. Having said this, it is important to include all options and accessories for your mold before obtaining authorization. I frequently will add summer/winter hardware to the back laterals to provide an appropriate fit when the client is wearing a coat or jacket. Additional covers, hardware, ventilation holes, and additional t-nuts are all covered items.

Finally, it is important to know and understand the various systems and manufacturers. For example, Ride Designs manufactures a system that is lightweight and narrow for manual wheelchair users. PRM is typically easier to modify after the system has been manufactured. And Contour U and OBSS offer different mounting options that are easier to maintain.

In the end, the goal is to provide a successful outcome that takes into consideration the goals that you, the therapist, and the family have created. Just take your time and remember that practice makes perfect. Happy molding!!!

Medicare ADMC: Untangling the Confusion about this Medicare Service for Mobility Products

Wednesday, October 19th, 2011

By Patrick Boardman

ADMC: Advanced Determination of Medicare Coverage

There seems to be a lot of confusion out there about ADMC. At Active American we utilize this voluntary service virtually every day. This program offers a great way to hedge your bets if you are unsure about getting paid for a Medicare item. In the Mobility arena these items are Ultra lightweight Wheelchairs (K0005 & K0009) and also Group II power wheelchairs with at least one power function, and Group III power wheelchairs. In our day to day operations, we often run into situations where chart notes or documentation is marginal. In this situation our best option is to utilize the ADMC program.

A few common scenarios where ADMC might be utilized:
1. Same or similar coverage identified by IVR system showing an existing chair on file within 5 years.
2. Limited or marginal documentation
3. Diagnosis or health condition that histroically has resulted in a denials for the type of product being recommended for the patient.

Now there are a few points to remember when submitting an ADMC request.

1. Utilize the checklist provided by Medicare: I cannot stress this enough.
2. Ensure that your dates for F2F, WO and DPD are accurate. For example, if your WO is dated prior to the date of F2F completion this will result in an obvious negative ADMC decision.
3. Ensure that you can attest and prove that an ATP was present and participated in the evaluation.
4. Be aware that if you omit just one document or one thing is out of order, Medicare will render a negative decision. If this happens you have only one more chance to resubmit. If you get a second negative decision you may not resubmit for 6 months.
5. The ADMC process takes about 30 days so factor this into your eval to delivery time frame.

With proper and correct documentation, using ADMC can be a great way to make sure that you stay in business!

Here are some helpful links with respect to ADMC: (This example and links are jurisdiction D so be sure to use the appropriate forms for your jurisdiction.

ADMC Cover Sheet-

ADMC Request Form-

List of HCPC Codes Eligible for ADMC-


ADMC requests may either be mailed or faxed to:

Noridian Administrative Services LLC
DME Jurisdiction D Medical Review
PO Box 6747
Fargo ND 58108-6747

ADMC Fax #: 877-662-8445

If you have questions please feel free to give us a call.

Patrick Boardman, Dir of Business Development
Active American Mobility and Medical Supply