November 2002

Making Moving Easier

By C.A Wolski

Like automobiles, mobility aids are ever-changing, with innovations and improvements occurring constantly. Among the groups shepherding this technology to practical realization is the University of Pittsburgh’s Department of Rehabilitation Science and Technology.

Mark R. Schmeler, MS, OTR/L, ATP, (right) discusses wheelchair caster suspension options with a client at the Center for Assistive Technology at the University of Pittsburgh Medical Center.

The department offers clinical services in addition to research and training, and its mission does not stop there. It also acts as an advocate for those with disabilities, a goal helped by the fact that several of the department’s 40 faculty and staff members—including the department’s chairman, Rory A. Cooper, PhD—have disabilities.

Over the last year, the department has witnessed changes in a number of areas related to mobility, from engineering to wheelchairs to reimbursement. These changes are not only improving the lives of those using mobility aids, but they also give a glimpse of where the future of this technology lies.

WHEELCHAIR INNOVATION

Manual-power hybrid wheelchairs are beginning to find a niche, in both research and the marketplace. “The one wheelchair we’ve been working on a great deal is the power assist pushrim-activated wheelchair. It’s a manual wheelchair that has a motor in the hub of the wheel,” says Shirley Fitzgerald, PhD, an assistant professor at the University of Pittsburgh and associate director of research with the Human Engineering Research Laboratory at the VA Pittsburgh Health Care System. “We have done a small clinical trial on individuals with paraplegia using this wheelchair, and we’re currently doing this on individuals with tetraplegia. The wheelchair will help reduce the strain on wrists, elbows, and shoulders, but still give people the flexibility of being in a manual wheelchair.” There have also been improvements in manual wheelchair suspension and seating systems, says Cooper. “We’re starting to see some products that use dynamic seating, so that, for example [for] children with cerebral palsy and people with cerebral palsy who are agitated … there is a little bit of compliance in the seating system besides the compliance of the cushions to help provide greater comfort,” he says.

Fitzgerald says that in the near term there will be improvements in ride comfort for manual wheelchairs through new casters and shock absorbers. She is also examining how components are holding up in real-world conditions. “I am actually following wheelchairs over time to see what is going wrong with them so we can apply that to develop better wheelchairs,” she says. “All of the testing that has been done on the wear and tear on wheelchairs and how they hold up have been in laboratory settings, according to international standards that are well known. My goal is to try to see if those standards hold up in real-world settings. The wheelchairs [we are following] range from manual wheelchairs, to power wheelchairs, to all types and brands and levels of wheelchairs in those categories. It’s still pretty early, but when we get those findings, we’re going to try to make the wheelchairs that are being developed now better, so if a certain type of caster keeps breaking, we’ll be able to go back and say, ‘This seems to be a problem, let’s fix that scenario.’”

Cooper adds that he expects to see other advances in power wheelchairs. “I think you’ll see more capabilities in power chairs [such as] the ability to negotiate different types of terrain such as curb climbing ... and negotiating soft surfaces like sand and gravel,” he says.

As for the distant future, Cooper speculates that there will be improved access to the technology. “I think new algorithms will make electric powered wheelchairs practical and driveable by a wider range of people with disabilities,” he says. “I think you will find manufacturing technologies that will allow more customization for individuals, or essentially local customization on a cost-effective basis.”

SCOOTER ADVANCEMENT

Although there have been improvements in prosthetics and other nonwheelchair mobility aids, one system that has not seen any recent improvement is the scooter. “Driving aids haven’t changed too much, except I do think there continues to be significant [progress in] improving the safety of wheelchairs, and there have been improvements in occupant restraints and tie-down mechanisms,” says Cooper. “A lot of that still is on the verge of commercialization.”

But there are changes on the horizon, Cooper says, including greater reliability, greater ease of transport, better stability, and the integration of the charger into the unit.

Cooper also sees scooter technology evolving in other ways. “You’re also going to see greater integration of power chairs and scooters, sort of a hybrid, like a fly-by-wire scooter,” he says. “Now you have to physically control the tiller. I think you’ll see scooters in the future where you have a tiller, or handlebars, but it’s electrically connected to the wheels, not mechanically [attached].”

In 50 years, Cooper speculates that scooters as we know them today will not exist. “You’ll have devices in 25 or so years that are mobility devices, and I think they will reach the performance level that [a nondisabled person] might want one,” he says. “I think power wheelchairs and scooters and that whole field have the potential to evolve in such a way that they offer significant improvements in mobility, and the level of impairment that makes them attractive will actually decrease.”

MOBILITY AID DELIVERY

Not only is the technology changing, but the way wheelchairs, scooters, and other devices are being delivered to patients is also evolving, albeit at a slower pace. This is being driven by a number of factors, including the increasing longevity and savviness of patients, says Mark R. Schmeler, MS, OTR/L, ATP, director of the Center for Assistive Technology at the University of Pittsburgh Medical Center. However, the advances in delivery mechanisms are not necessarily beneficial to the patient yet. “We’re seeing a lot of advertising in the mass media for mobility devices, which isn’t necessarily resulting in people getting the most appropriate devices, because they’re going directly to some supplier who probably doesn’t have any expertise at all in the rehab community,” says Schmeler. “I’ve seen a big increase in that over the last year. [There was] a lot of Internet-based, dot-com access to the equipment, and people ended up getting equipment drop-shipped to their house, in a box left on the front porch. They can’t use it, can’t get it into the house, it doesn’t work for them, but their Medicare has already been billed and they can’t return it and they’re stuck with it.”

As bad as this can be for the patient, this situation will change, says Schmeler, as consumers become better educated and more proactive about their demands for better equipment and service. He also hopes that new coverage rules will require that patients receive an assessment by a qualified clinician before purchasing a device. More fundamentally, he sees a need for a change in the outlook on wheelchairs and mobility devices by the medical community, which he believes views wheelchairs as signs of failure. “Everybody’s reluctant to prescribe a wheelchair because they feel if somebody stops walking, they’ll never walk again,” says Schmeler. “The reality is we’re going to have a population of very active older people with mobility impairments who want to be able to go where they want, when they want, in their community, and do what they want. I think that will drive the market.”

IMPROVING REIMBURSEMENT

Going hand-in-glove with delivery is reimbursement. Again, not much has changed in the last year, but there are encouraging signs on the horizon. New wheelchair codes have been proposed that are based more on scientific principles, and this will help rehab professionals and providers of mobility systems to develop new products that match devices to the patient’s real needs.

In addition to having a more scientific basis, Schmeler says the future will bring a more market-driven approach to reimbursement. “As service delivery models change, as funding models change, consumers are going to have more control over how their health care dollars are spent, where they’re spent, and what’s important to them, so that will drive the market,” he says. “I think there will be a minimum coverage allowable for certain health care [products], and people will have the choice of getting the standard device or an upgrade.”

HIGH-TECH EFFECTS

It is technology’s cutting edge that holds the most promise for the future, and this is what most obviously excites Cooper, who has defined six core areas that he sees dominating mobility technology in the coming decades. They include: communications, computing power, nano-technology, automation, genetic engineering, and manufacturing technology. “In communications, I see advances in voice text and data transmission [and] electronic record-keeping—which will make clinical work more efficient and more effective,” he says. “I think you’ll see more Web-based education, especially client education and continuing education. If you look at computing power, I think that will lead to advances in modeling at the molecular, cellular, organ, organ-system, and whole body level. So [that will improve] engineering applied to the body and essentially how the body works.”

Cooper’s intriguing speculations about nano-technology sound like something out of an episode of “Star Trek.” “I think in nano-technology we’re going to see miniature implantable sensors … that could help modify the technology,” he says. “[There could be] nano-repair robots, little robots that would go in and repair tissue. For example, let’s say you’re a below knee prosthesis [user] and the robot can be injected into the knee to maintain and repair the [stresses caused] by the prosthesis. Tissue-to-technology interfaces [are] where I think nano-technology will have the greatest response for people with disabilities. Imagine if you introduce sensors into a person’s blood and those sensors could measure capillary [oxygen], and that information could be [transmitted] to the cushion, and the cushion could alternate its shape in response. You could have a big impact with something like that on pressure ulcers.”

Beyond these core areas, Cooper also sees other improvements in the area of computer modeling, the increased use of telerehabilitation, and growth in the use of microelectronics.

IMPROVING QUALITY OF LIFE

More important than the leap forward in technology itself is the way it will improve the lives of those who need mobility aids. “The pushrim-activated wheelchair [will make] changes in quality of life that are going to be dramatic for individuals who feel that they can’t go places because they don’t have the strength and they haven’t been prescribed a power wheelchair,” says Fitzgerald. “They’re going to be able to get out and interact with the community and do activities they like that they may have done years ago, but [gave up] because of the progression of their disability.”

For Fitzgerald, technology is just the means to her ultimate goal. “I think that some of the wheelchairs are going to make it possible for people to maintain or get back to an active lifestyle, [doing] what they wanted or want to be doing,” she says. “And if you impact that, then the other psychosocial problems that go along with being stuck in the house will go away. If you can get out, you are less likely to be depressed. If you can get out, you’re more likely to go to work. That ultimately is what I want to see happen---[that] however the wheelchairs get designed, they are able to meet people’s needs, so people can have productive lifestyles.”

C.A. Wolski is associate editor of Rehab Management.

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