Diagnosis: Muscular Dystrophy
Subject: prescription for power wheelchair and seating equipment
To Whom It May Concern,
——————— is a 19 year old male patient of mine with the above diagnosis who is non-ambulatory and is unable to propel any type of manual wheelchair. He is dependent upon a power wheelchair for all functional mobility at home and in the community. He has recently graduated from highschool and is preparing for enrollment in a college later this year. He requires a new power wheelchair base with upgraded electronics and custom fitted seating and drive controls to support his independent functional mobility at home, in the community and to support his independent access on his college campus.
Currently, ——- is using an Invacare power wheelchair (serial# 00000000) that is several years old. There have been several repairs made to this wheelchair in the past few months and there is current concern over needing to replace drive motor(s) and/or gear boxes. All 4 tires are severely worn and in need of replacement as well. ——-also reports having increased difficulty driving this power wheelchair up inclines and maintaining the position of his right upper extremity to allow for joystick access with right hand. He is unable to utilize the foot supports on this chair because of the overall length of the power wheelchair with them attached. His access/mobility is restricted in turning thru doorways at home as well as maneuvering thru his van, hallways and other spaces at home and in the community. The seat back on the current power wheelchair provides no contact or support when ——– is seated upright or in moderate tilted angles and only provides minimal support when he is in full tilted postures. There is no accommodation designed in the current seating or power seat functions for the significantly hyper-lordotic spine/trunk posture that dominates ——– sitting position/posture. Consequently, he sits unsupported the majority of the day resulting in significant motor and respiratory fatigue. Finally, the current power wheelchair does not provide the electronic interface modules to environmental access controls or remote computer access controls which ——- desires and will need to further facilitate his independence at home, school and in the community/work environment(s).
Due to the nature of his diagnosis, ——–is dependent for all transitional mobility, transfers, bed mobility, re-positioning, and ADL’s including feeding. He is unable to stand or bear weight on lower extremities and he is unable to sit unsupported. He recently began using a bi-pap machine Page 2/————————-
at night due to respiratory compromise. He also has a cardiomyopathy that is being treated medically. His upper extremity functional mobility is significantly limited by his progressive loss of motor function. Currently, he can operate the power wheelchair using his right hand when the forearm is supported on a padded trough. He grasps the extended joystick between his first and second fingers with his wrist in extension and ulnar deviation and his forearm in neutral or slightly supinated. He primarily uses gross motor movements at shoulder to push or pull hand in controlling the joystick. Alternative drive controls were explored with —— but did not appear to support his independent control of the joystick as well as his current method. However, he is having increased difficulty moving his forearm across the arm trough surface material due to excessive friction but also reports being unable to support his forearm/hand in position when tilted if forearm trough becomes wet/slippery from his perspiration.
———- presents with an anteriorly rotated pelvis and hyper-lordotic spine/trunk that has been stabilized with rods in 2000. His head control is good when he is in upright seated postures but he requires posterior and lateral support of his head when he moves into tilted postures. As indicated, ——- cannot seat upright without support including lateral trunk supports, anterior chest support and posterior back support. His righting reactions and protective reflexes are delayed and/or impaired and he is unable to perform independent pressure relief techniques due to upper extremity weakness. Therefore, he is at significantly increased risks for skin breakdown.
In order to provide safe supported seating, accommodate for postural abnormalities, facilitate independent functional mobility and reduce risks for secondary complications such as skin breakdown, contractures and deformity as well as facilitate environmental access and functional independence at home, school and in the community, the following equipment is recommended and is considered medically necessary:
1) Invacare TDX-SP power base (short) with MARK VI electronics; transport
brackets; 8 inch casters with shock forks; 14 x 3 inch foam filled tires; compact 1812 joystick with display; Gatlin adjustable joystick mount; straight handle flexible joystick extension; Communication Module 1 &2 for environmental/computer access thru power wheelchair electronics.
2) Motion Concepts Ultra-Low TRx-CG power seating system for Invacare Storm Arrow base with 55 degrees power seat tilt; 174 degrees power seat recline/30 degrees power seat pre-cline; TRx elevating seat module; 16w/18d seat pan with 2 inch narrower seat back; 19 inch back height with 22 inch tall back canes and standard Rehab back pan and pad; reclining height adjustable arm supports; TRx elbow blocks; 2 pairs of TWB lateral supports for trunk and hip guide alignment/support; fixed 90 degree center mount interface bracket with flip-up footplatform 11in x 10 inch; enhanced 2-5 function electronics to allow control of drive/seat functions thru joystick with standard scan mode select upgrade; Trx M16 splitter and accessory port power supply to accommodate environmental/computer access thru power wheelchair electronics. The power pre-cline function is needed to facilitate back support and accommodate for ———– abnormal structural trunk/spinal posture; power pre-cline is not Page 3/——————–
available without power recline function; power tilt is needed for pressure relief and to facilitate trunk posture/alignment improving head control and supporting respiration, communication and swallowing; the footplatform is required for lower extremity support.
3) AEL chest support strap to fit between lateral trunk supports to prevent forward trunk collapse.
4) AEL arm troughs with adjustable hardware mounts and wrist straps to facilitate positionijng of upper extremities and reduce risks for injury to upper extremities from falling off of arm supports when in tilted postures or when operating power wheelchair drive function.
5) Freedom Design custom headrest with removable cover to support head when in tilted positions and when driving power wheelchair.
6) Freedom Design mild contour seat insert to accommodate for pelvic and lower extremity positioning and to reduce risks for contractures, deformity and skin breakdown.
Thank you for your attention in this matter.
This copy is provided by Active American Mobility and Medical Supply. No restrictions on distribution.
Contact Patrick Boardman 281-495-4400