Providers of powered mobility devices (PMDs), including power wheelchairs and scooters, can have a tremendous impact on the lives of people with limited mobility. Research shows that these devices improve the functional capacities of people who cannot safely or effectively ambulate or propel manual wheelchairs.¹

Matching a person with the most reasonable and appropriate device is paramount in ensuring a successful outcome. Studies of assistive technology abandonment indicate that improper assessment of consumer need is a major factor.² Or, in other words, unless the device matches the needs of the consumer, that person will give up and stop using the device.

However, to date, there are no standards as to who can provide PMDs under the Medicare program other than requiring a completed Certificate of Medical Necessity (CMN) signed by a physician. This leaves providers who insist on high standards for how their companies sell PMDs open to competition from companies that simply put patients in one-size-fits-all lowest-dealer-cost PMDs.

In addition, it puts PMD users at risk because unless they know to look for signs such as a provider being accredited, being a member of a purchasing group with a code of ethics, or employing staff with rehab degrees, the users get no assurances of minimal training requirements or standards of practice.

This is especially of concern with the recent onslaught of mail-order and Internet-based suppliers who capitalize on the lack of standards and minimum documentation requirements and drop ship one-size-fits-all lowest-dealer-cost PMDs to older people who have never been carefully assessed or provided with opportunities to try devices to verify that they meet their needs.

These drop-ship sales practices hurt providers with high standards for selling PMDs by furthering the belief that the HME industry is made up only of suppliers of bent metal with wheels and motors ready to be loaded on a truck for delivery with no regard to the professional services behind the equipment.

Continuation of these practices will hopefully lead to the implementation of higher quality standards but will probably result in sanctions on the industry as a whole. Then these drop-ship companies will most likely move on to other opportunities that can be exploited leaving the longtime providers to deal with the repercussions of these companies’ sales practices.

The Case For Industry self-regulation
The Rehabilitation Engineering & Assistive Technology Society of North America (RESNA) has introduced the first voluntary certification program to address this issue. However, Medicare and many other payor sources have yet to adopt its Assistive Technology Practitioner (ATP) and Assistive Technology Supplier (ATS) certifications.

Best practices for the assessment and provision of PMDs are poorly defined, and current coverage criteria are antiquated and conflict with accepted standards of practice for licensed health care professionals. For example, Medicare policy includes restricting coverage primarily for use in the home and requiring physician certification that the user is unable to ambulate, cannot operate any type of manual wheelchair, and has severe weakness of the upper extremities. These standards are in contrast to current research evidence.

Fortunately, Medicare stops short of providing a specific operational definition of home, ambulation, ability to propel a manual wheelchair, or severe upper extremity weakness. Therefore, practitioners should use their clinical interpretations and render judgments regarding the person’s situation and capabilities.

“Matching a person with the most reasonable and appropriate device is paramount in ensuring a successful outcome.”
—Mark R. Schmeler, MS, OTR/L, ATP, director, Center for Assistive Technology, University of Pittsburgh Medical Center Health System

Practitioners should define home as the places where all necessary activities of daily living occur including the actual home as well as the community. They should assess ambulation from the perspective of the surfaces and distances encountered in a routine day and whether walking or pushing a manual wheelchair is safe and efficient. Finally, when considering manual wheelchair propulsion, they should also think about the stress being applied to the upper extremities, which has been associated with upper extremity repetitive strain injuries.³ There is no evidence that upper extremity strength correlates with the ability to propel manual wheelchairs, especially when one considers people with cardiac or pulmonary impairments, arthritis, multiple sclerosis, or cerebral palsy.

Best Practices
When providing a PMD device, it is essential to conduct a careful and methodical evaluation of a potential PMD user with clinical input from trained professionals familiar with these types of devices. Based on consensus in the industry,⁴ there are four key variables a scrupulous PMD provider should consider before providing a power chair.

1. Physical and functional considerations. Height and weight alone are not indicators to determine seating and positioning needs. Joint range of motion, especially at the hips and knees, as well as pelvic and spinal alignment, will determine the proper configuration and postural supports of a seating system.

Imagine an older person with an arthritic hip that cannot be flexed more than 60 degrees sitting in a chair with a 90-degree seat to back angle. Or consider a person with a 14-inch thigh length sitting in a seat with a 16-inch seat depth that forces them to slide forward into a posterior pelvic tilt and slouch.

The risk for and presence of skin breakdown needs to be considered for proper seat cushion selection. There is only one Healthcare Common Procedure Coding System (HCPCS) code and allowable for the dozens of pressure-relieving cushions on the market, and each cushion has advantages and disadvantages that need to be carefully considered similar to how a physician prescribes medication based on benefits and side effects. Inappropriate seat cushion provision can lead to costly and deadly pressure sores⁵ as well as affect the user’s postural alignment and his or her ability to transfer in and out of the chair. Features such as tilt-in-space and reclining-back systems need to be considered for people who cannot physically adjust or reposition to reduce the potential for postural deformities, discomfort, and skin breakdown.⁶

Finally, the nature and progression of the underlying disease also need to be well understood and factored into the design of the intervention. As the user’s condition progresses, a PMD may need to accommodate alternative controls—if the person will be unable to operate a proportional joystick—as well as the addition of features such as a seat elevator, tilt, or recline.

2. Driving abilities. A PMD is a heavy piece of equipment capable of reaching high speeds. This means it can gain enough momentum to cause serious property damage, injury, and even death in a collision. Therefore, the provider must carefully assess a candidate’s ability to operate heavy equipment before supplying the device, especially when the candidate has cognitive or perceptual deficits. People with these deficits should not be precluded from the use of a PMD. However, they may require training to learn to operate the device.

3. Environmental accessibility. A home assessment is often needed to ensure the device will be compatible. Because few if any PMDs can be readily carried up stairs, negotiated through narrow doorways, or made to do tight turns in a hallway or bathroom, a proper assessment involves taking the device to the home, surveying the environment for accessibility, and having the potential user get into the device and drive it where he or she may travel within a routine day.

The home assessment should also involve having the candidate complete specific tasks he or she will need to perform from the device. This includes transferring to various surfaces, reaching for objects, cooking, pulling up to a table or work surfaces, and completing any other vital activity.

Finally, the assessment also needs to appreciate that some potential users may not perform well at first and might need some remedial training. The user also might not consider certain vital activities when caught up in the euphoria of possibly getting a PMD. However, when the novelty wears off, the user may identify factors that render the device impractical.

4. Transportation. Recent advertising, especially on television during prime late morning game shows, gives consumers a sense that PMDs can easily be placed in a vehicle. Although this is feasibly possible in some instances, the physical capabilities of the person stowing the device must be considered. Often the person stowing the device is an elderly spouse with his or her own physical limitations. If transporting the PMD is essential, the person who will be conducting the task should get an opportunity to stow the device to verify the operation is feasible.

If a consumer will use an accessible vehicle, such as a van with a lift or ramp, that consumer will need to drive the device into the vehicle, maneuver it into an appropriate position for securement or transfer to another seat, and then exit the vehicle. It is crucial to consider a device that has the appropriate attachment points to ensure optimal safety during transportation.⁷

Clearly, PMDs cannot be arbitrarily provided without a proper assessment that carefully considers several variables related to the user and issues related to environment and transportation resources. Because current Medicare coverage policy is antiquated and does not necessarily consider all these issues, it leaves potential PMD users and providers with high standards for how PMDs should be sold vulnerable to providers more concerned with profits than finding the most appropriate device for a potential customer.

Mark R. Schmeler, MS, OTR/L, ATP, is the director of the Center for Assistive Technology at the University of Pittsburgh Medical Center (UPMC) Health System and instructor in the Department of Rehabilitation Science & Technology at the University of Pittsburgh.

References
1. Buning ME, Angelo JA, Schmeler MR. Occupational performance and the transition to powered mobility: a pilot study. Am J Occup Ther. 2001;55:339-344.
2. Phillips B, Zhao H. Predictors of assistive technology abandonment. Assist Technol. 1993;5:36-45.
3. Boninger ML, Souza AL, Cooper RA, Fitzgerald SG, Koontz AM, Fay BT. Propulsion patterns and pushrim biomechanics in manual wheelchair propulsion. Arch Phys Med Rehabil. 2002;83:718-723.
4. Angelo J, Buning ME, Schmeler M, Doster S. Identifying best practice in the occupational therapy assistive technology evaluation: an analysis of three focus groups. Am J Occup Ther. 1997;51:916-920.
5. Brienza DM, Karg PE, Geyer MJ, Kelsey S, Trefler E. The relationship between pressure ulcer incidence and buttock-seat cushion interface pressure in at-risk elderly wheelchair users. Arch Phys Med Rehabil. 2001;82:529-533.
6. Sprigle S, Sposato B. Physiologic effects and design considerations of tilt-and-recline wheelchairs. Orthopaedic Physical Therapy Clinics of North America. March 1997;6:99-122.
7. Van Roosmalen L, Bertocci GE, Hobson DA, Karg P. Preliminary evaluation of wheelchair occupant restraint system usage in motor vehicles. J Rehabil Res Dev. 2002;39:83-93.