An ultra-lightweight, customized wheelchair can enhance the user's efficiency and functionality.

Custom-built—as well as customizable—manual wheelchairs employing amazingly lightweight materials can, in the right circumstances, contribute to improved user efficiency and functional skills, many rehab professionals now recognize.

Unfortunately, many payors—with Medicare leading the pack—do not share in that enlightenment. Typically, they lack coverage policies making clear the who-what-when-where-and-why of qualifying a user to receive a reimbursed ultra-lightweight manual wheelchair.

The lamentable result is that many individuals who could benefit from being prescribed an ultra-lightweight product are instead ushered into wheelchairs of a less than optimal type, clinicians and suppliers report.

"Because the perception is that Medicare won't pay for wheelchairs in the K0005 and K0009 code categories, many in our profession don't even bother looking into whether an ultra-lightweight manual wheelchair would be the best choice for their client—they go straight for product in the manual K0001 through K0004 category; or, alternatively, they try to put the individual in a scooter or power wheelchair because Medicare's coverage policy for power mobility devices is much better defined than it is for the K0005s and K0009s," says Mark R. Schmeler, PhD, director of continuing education in the Department of Rehabilitation Science and Technology at the University of Pittsburgh.

However, he points out, Medicare does in fact reimburse for ultra-lightweight manual wheelchairs. It is just that the clinician requesting these wheelchairs must convincingly document that the wheelchair user is highly active and needs this particular class of mobility device in order to adequately engage in their required activities of daily living while, at the same time, remaining independent.

ONE FOR EVERY NEED

Today's ultra-lightweight manual wheelchairs are barely equal in heaviness to two one-gallon containers of supermarket milk. In some cases, the wheelchair weighs even less. As such, ultra-lightweight wheelchairs are preferred for (and by) users who put a premium on performance and who need a mobility device that is the easiest of any to transport.

Scarcely a wheelchair maker exists that does not offer ultra-lightweight product. These wheelchairs fall into three categories. Rigid ultra-lightweights are the most in demand because they weigh the least, thanks to the absence of pounds-adding mechanisms of the sort found on folding ultra-lightweights, the second of the three categories. Folding ultra-lightweights are best for users who travel in gas-saving smaller cars or live in rooms where space is at a premium, but who also do not mind giving up a bit of wheelchair performance as the price of being able to collapse the device for stowing or storage. The third category of ultra-lightweight wheelchair is the durables—those constructed of titanium, whose properties are such that the finished product is simultaneously the lightest and strongest of any on the market.

Wheelchairs in each of these three categories further divide into two subclasses: custom-built and customizable. "It's important to appreciate the difference between custom and customizable," says Kendra Betz, MSPT, ATP, prosthetics clinical coordinator with the Prosthetics and Sensory Aids Service at the VA headquarters in Washington, DC. "The custom wheelchair is completely designed and welded to be an exact match for the individual who will be using it. The customizable wheelchair has multiple adjustable components that allow it to be fit to the user on delivery."

Custom and customizable ultra-lightweight manual wheelchairs each have pluses and minuses. "The custom wheelchair will typically be lighter in weight and lower in maintenance with improved performance because there are few moving parts," says Betz. "But the downside of a custom wheelchair is that what you see is what you get. You therefore need to be able to give the manufacturer absolutely correct measurements, and that takes confidence and competence from both the clinician and supplier."

Physical dimensions and body strength are paramount considerations when choosing mobility devices.

"Then there is the customizable wheelchair. This is the one you take out of the box and make whatever adjustments are necessary to fit it to the user," she says. "The downside is the adjustments require the addition of movable hardware, which increases wheelchair weight and carries with it the need for greater maintenance. One example of this is the adjustable cantilever or monotube-type wheelchair. It's the hot, new thing. Most of the manufacturers are offering cantilever frames, and it's what a lot of the end users are asking for because of the look and styling. But the cantilever frame is the embodiment of minimalist design. Consequently, all components have to be added by bolting on hardware and adapters. When multiple adjustments are available on a cantilever frame, the weight of the necessary hardware adds up fast, which is a critical consideration when every ounce matters."

THE PUSH IS ON

Like cantilever frames, fully custom wheelchairs—while themselves not new—are enjoying a spike in popularity.

"Custom frames are preferred by experienced wheelchair users who know exactly what they want in a frame—and exactly what they don't want," says Schmeler. "What they don't want are adjustments and hardware add-ons because of the increased weight and maintenance involved."

Alas, many clinicians and suppliers back away from prescribing custom-made wheelchairs. Reason: fear of making a measurement mistake. "If they're off on the specifications they give to the manufacturer, the delivered chair won't quite fit right and then they're stuck," says Schmeler. "Once the measurement error is translated into a completed chair, nothing can be done about it. The chair can't be changed—and it can't be returned to the manufacturer."

Not surprisingly, those who worry about measurement errors often decide the safest course is to turn to a customizable wheelchair. That, suggests Schmeler, can actually be the smart play if the user is too new to wheelchairs to have yet figured out what he likes and dislikes, what he must have and what he can forego.

Betz, however, thinks an even better option is to order an ultra-lightweight wheelchair that is custom, yes, but not entirely. "I like the kind that allows for some postdelivery adjustment," she says. "The nice thing about them is they let us designate some of the dimensions that we can be fairly confident with, and then later adjust some of the other dimensions as needed in response to the user's needs. For example, if we correctly perform a comprehensive evaluation and assessment, we can in many cases determine a couple of dimensions like rear- and front-seat-to-floor height, and rear wheel position in a vertical dimension. We can figure these out ahead of time, and in so doing minimize the adjustability that's necessary in that particular wheelchair. But things I would want to be adjustable—especially for users new to manual wheelchairs—are the rear wheel fore and aft in the horizontal dimension, back height and angle, and foot plate height."

The comprehensive evaluation and assessment mentioned by Betz is most useful "if it takes into consideration the user's intentions for where and how the device will be operated," she offers. Schmeler proposes that the first order of business should be to discover whether the client is even able to push a properly configured manual ultra-lightweight wheelchair. "Some of the basic issues here are anatomical dimensions, range of motion, and strength—the same as for any wheelchair assessment," he explains. "Also, you need to resolve things like how well and fast the client moves, and whether they are putting themselves at risk of injury to their upper extremities while propelling the wheelchair."

Ultra-light wheelchairs are more easily maneuverable, as well as more durable and cost-effective.

A MATTER OF LEARNING

Becoming proficient at evaluations and assessments takes training rooted in solid education. "The more you know about not only the process but also about the product choices and payor policies, the greater confidence you'll have when it comes to designating the specifications for a chair that is either partly or entirely custom-fabricated," says Betz. "Because, if you don't have the competency and confidence to do so, you may think you're better off prescribing something other than a K0005."

Physical dimensions and body strength are paramount considerations when choosing mobility devices.

Betz asserts that education should come from both the manufacturers and objective, independent sources. "An excellent resource for learning more about the technologies that are available, as well as client-specific recommendations, is the International Seating Symposium (ISS)—both on the West Coast with the Vancouver Group and on the East Coast with the University of Pittsburgh Group," she says, noting that she and Schmeler jointly delivered a presentation at the recent ISS-Vancouver meeting on the subject of whether and under what conditions it is most appropriate to prescribe manual or power mobility (the meeting also included a half-day session on manual wheelchair selection, configuration, and objective measurements surrounding propulsion and another session on education for manual wheelchair users).

Among the hats worn by Betz is that of director of training for a Paralyzed Veterans of America (PVA) Education Foundation grant. Her role there includes providing education about clinical practice guidelines for upper limb preservation. "We've just completed seven full-day seminars around the country—a current project of ours is to transfer that seminar into an online format so that it's more readily available nationally and internationally," she says.

For his part, Schmeler also strongly advocates clinician continuing education concerning manual ultra-lightweight wheelchairs. "I'm leading a program here at the university in which we're coordinating live, in-person seminars and making them and other programming available on the Internet," he says. "For example, we currently have a 90-minute Webinar on optimally configured manual wheelchairs [accessible at www.rstce.pitt.edu]. Education of the clinician is key, and that's being worked on aggressively throughout the profession."

Equally important is that rehab professionals—and consumers—learn to be strong advocates able to make the case as to why manual ultra-lightweight wheelchairs should be appropriately reimbursed. "Word needs to reach lawmakers and regulatory agency leaders," says Betz.

Rich Smith is a contributing writer for HME Today.