December 2005

Optional But Necessary

By Danielle Cohen

Wheelchair accessories can improve the function and health of patients

While the frame, wheels, seat and back upholstery, armrests, and footplates come standard with the average wheelchair, often, depending on the user's needs, those standard features may not necessarily be the best or most appropriate. Other accessories may be required as well.

"Everybody requires some sort of [wheelchair] accessory," says Rachael Grace Finke, PT, who works in the wheelchair clinic at Spaulding-Framingham, an outpatient facility in Framingham, Mass, that is part of the Spaulding Rehabilitation Hospital Network.

Wheelchair accessories are often required for everything from assisting with positioning to relieving pressure to carrying objects.

ACCESSORIZING
Among the more common wheelchair accessories used today are side guards; tool packs; headrests; seat pouches for keys and wallets; cup or bottle holders; pneumatic or spoke tires; heel loops; back or seat elevators; swing-away, elevating, or elevating/articulating footrests, or those with an angle-adjustable footplate; brake extensions for those wheelchair users who need help reaching the brakes or whose hands are too weak to lock the brakes; swing-away joystick mounts so that patients can move closer to an object, such as a table; push handles, especially flip-down models that can be moved out of the way when the user folds the wheelchair to place it in a car, for instance; and adaptive cushions, including multi-foam or gel models, to help prevent skin breakdown or maintain postural alignment for patients who have orthopedic deformities.

"You shouldn't really be sitting in a wheelchair without some type of cushion, but if you even want a basic foam cushion, it's [considered] an accessory," Finke says. "Armrests are standard, but it's not standard to have a removable armrest or a height-adjustable armrest or a flip-back armrest, and it's essential to have your arms in the proper resting position so that you're positioned well and you don't make any pathology worse."

Finke primarily works with patients who have multiple sclerosis, postpolio syndrome, and other neurological populations.

While many wheelchair users have backpacks nowadays, David Kreutz, PT, ATP, who works in the seating and mobility clinic at Shepherd Center, an Atlanta-based catastrophic care hospital, says he prefers an under-seat pouch or other carrier for manual wheelchair uses. "It keeps the center of gravity low and doesn't make the chair unstable. Hanging all of that weight on the back of the chair of a child or young adult who's going to school...is enough to really throw off the center of gravity," he says.

Along the lines of safety, Kreutz says crutch or cane holders are also important accessories for those who use that equipment. "It's kind of hard to carry something in your lap. If it falls off the chair, it could stop it prematurely and cause an accident," he says. "If somebody does ambulate short distances and uses a chair for long distances, when they get somewhere and they need to be able to walk into a bathroom, for instance, they've got their cane or crutch with them."

Patients with an amputation may require additional wheelchair accessories, as well. The axis of the wheels may need to be changed so that the individual is seated with their new center of gravity in the center of the chair. If the patient does not wear a prosthetic limb, they may require a special cushion to support the residual lower limb. Such a cushion is usually custom-made with one side longer than the other, so that the residual limb can have the knee in extension and avoid the risk of knee flexion contracture. In addition, a stump support or an insert may be needed under the cushion for added stability.

Over the years, the increased use of some equipment has moved them from accessory status to standard equipment. These include lap trays, upper extremity support trays, wheel locks, seatbelts, and anti-tip bars. The change in the status of such items as seatbelts and anti-tip bars can be attributed to safety concerns.

"Some people consider anti-tip bars accessories, but they're pretty necessary in most cases," Kreutz says. "Most manufacturers put [anti-tip bars] under optional features, and I don't consider that an option unless somebody is really independent in their wheelchair. I tell people that if they're really concerned about the weight and lifting the chair for loading into a car, they need to keep their accessories to a minimum because all of that starts adding up."

"There are some patients," Finke adds, "[such as] someone who is a high-level paraplegic, who might opt to get rid of armrests or anti-tippers or seatbelts because they add to the weight of a chair. These are people who want to be able to take apart a chair and be able to put it in their car independently, so it's to their advantage to have the most lightweight and efficient chair there is."

Among the newer wheelchair accessories on the market are attendant drive controls for power wheelchairs. "These power chairs are about 250 to 300 pounds now, and if the person weighs another 250 to 300-plus pounds, you're talking about 500 pounds; some of these chairs don't disengage easily, so it's almost impossible to push them," Kreutz says. "Having an attendant drive can be very beneficial to get somebody around."

APPROVAL REQUIRED
No matter which wheelchair accessory is desired, in most cases, the equipment must be approved by the insurance carrier to avoid having the user pay out of pocket or losing the chance to have the equipment altogether.

"You have to justify these things from a medical standpoint in order to get them covered, in a lot of cases," Kreutz says. "If you can relate them to safety or function, then I think they'll get covered."

For example, Kreutz says that to get approval for spoke guards for a high-level quadriplegic whose fingers get caught in and cut by the spokes, the justification would be functional—preventing injury. If a very functional paraplegic wanted the spoke guards for aesthetic purposes, however, they most likely would not be covered, he says.

Generally, it is the physical therapist who writes a letter of justification that supports the need for each item. Finke says the key to reimbursement is to be savvy in writing a letter of medical necessity. "To write a really comprehensive letter of medical necessity, you have to write the patient's complete medical history, state the decline in status that requires them to have the device, and justify each piece," she says, adding that failure to do so can make or break whether a request receives approval.

Finke advises using language that explains that the device would improve the patient's independence and their quality of life in the home and in the community. She also advises getting the referring physician's signature, along with that of the physical therapist, on the letter of medical necessity. "It's also good to compare things that were ruled out," she says, adding that insurance companies can be informed that other less costly items were tried, but were less effective, and therefore, the item being requested would be more appropriate.

Finke says vendors can often coach the therapists on writing letters of medical necessity, as they explain how their products are used and why they are beneficial.

If approval were denied, patients have the option of purchasing the wheelchair accessory themselves or seeking funding through other means.

Danielle Cohen is a staff writer for Rehab Management.

LOOKING FOR EXPERT ADVICE? Experts here are available to answer all your questions! Please contact us for more information about this feature, or to become an expert.

MEDIA CENTER Interactive Media  Archives  · December 2008  · November 2008  · October 2008  · August/September 2008  · Fall 2008 Product Directory  · July 2008  · June 2008  · May 2008  · April 2008  · March 2008  · All Archives  Newsletter  · Rehab Today Resources Classifieds Calendar Consumer Resources Media Kit Advertiser Index EAB Reprints Submit an Article