Prescribing Independence

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December 2003

By Sheila Buck, BScOT, ATP

Sheila Buck, BScOT, ATP, works with client George Ace.

For some clients, scooters are the perfect fit.

Scooters are mobility devices that can greatly enhance the lives of those who are feeling shut in or cannot move about as well as they used to. Unfortunately, labels such as “handicapped” or “disabled” often scare people away from discussing the use of alternate mobility devices. They may also use the excuse that “I need to keep walking or I’ll never walk again,” to avoid addressing mobility needs. As a result, people limit themselves to staying closer to home and no longer enjoy the freedom to leave their residences by choice.

Power mobility may be a consideration if the following points are reviewed with the client and have positive outcomes. First, the client wants to have independent participation in a greater range of activities, for greater lengths of time than may be possible in a manual wheelchair or with the use of a wheeled walker. Second, the client, as well as the family, facility, school, and community, is ready and willing to accept power mobility. Clients and caregivers must be comfortable with the powered device and the consequences of owning it (funding, repairs, manual operation, and maintenance). Finally, the client demonstrates functional skill development in the areas of attention vs distractibility, motivation for independence, persistence, adaptability to new situations, responsibility, motor planning, and judgment.

Reasons to pick a scooter

Difficulties in maintaining longer distance walking may arise from a number of physical limitations. If one or more of the following impairments are identified, your client may benefit from the use of a scooter to increase independence and conserve functional energy: arthritis or multiple joint replacements, heart condition, breathing difficulties, leg vascular difficulties, obesity, lower leg amputation, degenerative disc disease, chronic back pain, or early stages of multiple sclerosis with predominant lower extremity weakness.

It is important that trunk stability, skin integrity, and transfers are assessed to determine ability to access and sit on a scooter, and these may be determining factors in moving the prescription forward to the use of a power wheelchair. Scooter prescriptions can provide many added benefits to clients who can no longer walk distances but have the capacity for higher level functioning. Some of these benefits include: joint protection and pain management for those with arthritis and overuse/repetitive strain syndromes; energy conservation; compensation for limb dysfunction; and enhancement of social skills through control over environment, improved self-esteem, improved body image, responsibility, risk taking, and interpersonal relationship development.

Scooter benefits

Although utilizing a mobility device may initially be overwhelming due to driving difficulties and the adjustment to the appearance of driving such a device, the gains can be significant. Energy can now be spent on tasks other than walking. Independence in completing functional tasks such as laundry, grocery shopping, work duties, and vacation sightseeing can make a significant improvement in one’s outlook on life and sense of well-being. Most people utilizing a scooter can still complete a minimal amount of walking and therefore will still walk to transfer on and off the scooter and to get around in confined spaces. Therefore, the belief that walking or exercising is not possible is true only when people limit themselves intentionally, or can no longer walk at all.

Scooters manufactured today have greatly changed to meet the needs of the consumer. Four-wheel scooters allow for increased safety and function over rural or rough terrain. Smaller three-wheel scooters have increased turning maneuverability for use inside homes, stores, and confined spaces. Heavy-duty scooters assist larger clients in maintaining independent mobility without straining their legs, heart muscles, and breathing capacity.

It is important to remember that scooters are motorized units and therefore drivers must be responsible for their actions. A client’s perceptual, cognitive, and driving skills must be assessed by a therapist prior to the use or purchase of a scooter to ensure safety. Continual observation of cognitive and perceptual performance skills should include the ability to plan the movement of the device, sequencing to ensure safety, insight and judgment into safe use for oneself and others, and ability to deal with distractions and sudden movement changes from other people or objects.

Client interview and assessment

In order to move into scooter trials, the following must occur during the client interview: exploration of a client’s past lifestyle and impact of changes on the client’s current functional capacity, current lifestyle, wishes for functional lifestyle changes, and comfort level with powered mobility.

The following factors then need to be assessed: diagnosis and prognosis—primary and secondary; physical and functional abilities and limitations for self-care (feeding, dressing), homemaking, developmental levels, and communication; postural evaluation including mat assessment and assessment of skin integrity, strength, coordination, tone, associated reactions, balance, and sensation; neuropsychological functioning including cognitive/perceptual/visual, insight, and ability for new learning and relearning; social support system; environmental access—home, vocational/school, leisure; transportation; transfers; and financial status.

Once the interview is completed, the following list of factors must be considered for the completion of a prescription for a scooter. For environmental access: indoor turning radius, for use in apartments and elevators; outdoor terrain considerations including battery size, stability, and traction; suspension, especially for those with back pain; incline angles for stability, especially for those driving their scooters up and down hills or steep ramps; and overall length and width for use in elevators and small apartments.

Factors for transportation include: ability to disassemble into manageable pieces; ramp weight capacity and edge heights and troughing for wheel size; and compatibility with public transit, trunk of vehicle, and lifts. Factors for transfers are: ability to move arms out of the way for transfers; ability to turn seat, access to levers on seat and tiller, and ability to reach with left or right hand; seat height to the floor to assist with independent mobility on and off the scooter; and ability to come close to objects for access, ie, tables, counters, and desks.

For vocational and leisure activities, consider: shroud durabil-ity—exposure of batteries or wires to environmental conditions; overall durability; battery range and method of charging (on-board vs off-board charger); ability to access in different environments: ability to turn seat and move arms; and size and position of basket (attached to tiller or off tiller for balanced loads). Clients with weak upper extremities or shortness of breath are recommended to use a basket off tiller to reduce the load and fatigue on arms.

Factors for seat support and comfort include: arm pad length, width, height, and angle adjustments for support of arm on tiller hand grips, as adjustable angle and length are imperative for those with heart difficulties. Consider the seat height from the floor pan for optimal leg position. This is very critical for those with arthritis and decreased range of motion of their leg (hips and knees). Also take into account seat width, depth, and adjustments for forward and reverse positioning to minimize back discomfort and support the legs and pelvis; back height, adjustments, and contours, especially for those with back problems; seat and back materials for environmental wear and tear; and clearance for foot maneuvering between tiller and battery boxes and angle of foot platform (three wheel has more room and may be flat or angled, four wheel has less room and may only be flat). This is critical for those with knee contractures or hip problems. It is also necessary to factor in the ability to remove a generic seat and add on rehabilitative seating to maximize sitting tolerances.

Finally, considerations for controls include the ease of adjustment lever function and position for hand use (tiller, seat), which is critical for those with weakened hand function on one side over the other; ease of operation and visual display for key style and speed control; position and ease of use of battery plug; hand controls for thumb, finger, and combination; and ability to alter speeds and sensitivity for physical changes over time.

Additional considerations

Third-party funding may or may not be available for the client to purchase the scooter. Regardless, it is important to fully assess the client and their potential use for the scooter. It may be their choice to use it as a sole mode of transportation if they do not own another vehicle. It is also critical to review the long-term need for the device. If there is evidence that the client has trunk stability issues that may decrease over time, a scooter may not meet their needs and therefore a power wheelchair may be more appropriate. However, many clients feel much more stable with a single post tiller in front of them instead of using a joystick, which provides no forward stability though the upper extremities. On some scooters, slight modifications may be made to provide lateral stability and pressure management through the seat materials, and through the capacity to mount a rehabilitative seating frame.

It is important to remember that although prescribing a scooter may be easier than prescribing a power wheelchair with seating, there are several critical factors that should be incorporated to ensure that your client receives the best scooter for their condition, and that it will meet their needs over time. It is also imperative that when providing clients with scooters, their caregivers are notified of important clinical identifiers to prevent future injury.

Sheila Buck, BScOT, ATP, is owner of Therapy NOW! Inc, an occupational therapy company in Milton, Ontario, providing private consultation and education on seating and mobility assessments and prescriptions.

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December 2003