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April 2005

By Robert Meehan, MSTP, ATP; and Robin J. Skolsky, MSPT

Justifications for wheelchair accessories have to take into account a wide range of factors

Manual wheelchairs have evolved over the years with many advances in materials and design. Titanium and carbon fiber materials are allowing lighter wheelchairs and components. Research has shown that full-time wheelchair users prefer adjustable axle, lightweight wheelchairs (K0005 Medicare code) compared to standard weight (K001) or high-strength lightweight nonadjustable (K0004) wheelchairs.^1,3 A wheelchair user can also benefit from a wheelchair with an adjustable rear axle to improve speed and efficiency of propulsion.^2,3 Rear wheel camber, as well as many other options, can also affect the efficiency at which end users can propel themselves. The lighter, adjustable wheelchairs tend to be more expensive. For example, a fully accessorized titanium wheelchair can cost more than $5,000. In the current health insurance climate, medical justification is critical to ensure payment for wheelchairs and the components.

The seating evaluation is typically performed by a physical therapist, occupational therapist, rehabilitation engineer, and/or a certified rehab technology supplier (CRTS). At Shepherd Center, we prefer to have a therapist and a CRTS involved in the evaluation. The job of the therapist is to perform a physical evaluation to identify postural problems and identify the seating and mobility needs of the client. Once the posture and seating needs are identified and a manual wheelchair is deemed most appropriate, then the client can be educated in wheelchair frames that will accommodate those needs. For instance, a client who weighs more than 250 pounds will have fewer wheelchair frames to choose from, due to the weight capacity of certain wheelchairs. Also a client who is not propelling a manual wheelchair will have difficulty qualifying for a lightweight wheelchair. The therapist and the CRTS should work together to identify which wheelchairs will accommodate the client’s needs and will be reimbursed. Some insurance companies have restrictions on the amount they pay for manual wheelchairs, like Medicare, which reimburses less than $2,000 for a K0005 manual wheelchair frame. Medical necessity is frequently denied for components like seat elevators for power wheelchairs or side guards and seat pouches for manual wheelchairs. Clients should be educated that the wheelchair and components they want may not be reimbursed by insurance even if there is medical justification. Negotiating with the insurance case managers and filing for appeals or exceptions are means to help overcome funding obstacles. Persistence is important because it can take multiple appeals to overturn a denial. Furthermore, it is beneficial for the evaluating therapists to be aware of funding assistance programs that states, communities, and support groups offer. For instance, in Georgia, the Brain and Spinal Cord Injury Trust Fund is set up to provide up to $5,000 annually toward equipment for Georgia residents who have a traumatic brain and/or spinal cord injury. An application as well as documentation from a physician and/or therapist are required, just as insurance companies would require. This is quite beneficial to a client who requires a manual backup wheelchair or who does not have durable medical equipment (DME) coverage.

Citing research in letters of medical necessity can help bolster your justification. Standard weight versus lightweight or lightweight adjustable wheelchairs is probably the most researched topic with manual wheelchairs. Parziale³ studied the effect of standard weight and lightweight adjustable wheelchairs on quadriplegics and high and low paraplegics. He measured vital signs and velocity on a 400-feet sprint and a 4-minute maximum distance propulsion in standard weight and lightweight adjustable wheelchairs. In a questionnaire, the wheelchair users reported a 91% preference toward the lightweight adjustable wheelchair, although only 58% of them used one. Speed tended to be higher with lightweight wheelchairs also, but only significantly for the 400-feet sprint and only with the higher level injuries. Distances propelled over 4 minutes were greater for the lightweight wheelchairs, but that was only a trend. In 1999, Beekman et al² studied a lightweight adjustable frame wheelchair versus a standard weight frame with full-time wheelchair users on a 20-minute propulsion trial. Speed was significantly higher for the adjustable frame wheelchair for paraplegics, but not quadriplegics. Paraplegics also had lower oxygen costs and higher distance traveled. When quadriplegics were combined as a group, they demonstrated increased distance and speed with the ultralight wheelchair that weighed 27 pounds. Other research has shown the benefits of an adjustable rear axle, which is available only in the K0005 style wheelchairs. When the rear axle is directly in line with the backrest, as in K0004 wheelchairs, the efficiency is less.⁴ These studies are only a few that have addressed the types of manual wheelchairs, and they do not emphatically state that the K0005 wheelchairs are better for everyone. There are clear advantages in efficiency, but there are many other factors to consider, like funding, wheelchair stability, durability, transportation, client preference, and functional goals.

Regarding stability, research has been conducted to distinguish the role of rear wheel camber in the stability of a manual wheelchair.^5,6 Camber, the angle of the rear wheel in relation to the wheelchair, is decided upon at the wheelchair evaluation. Camber will allow for increased turning speed and lateral stability, but there are some consequences as well. There are some wheelchairs that offer a camber tube or adjustable camber on the axle; for most, however, camber is a degree determined and set on the chair. In a study by Trudel et al in 1995, it was concluded that increasing the camber of a wheelchair will increase the wheelchair’s track width, increase the wheelbase, and decrease the height of the wheelchair. Furthermore, it was noted that the center of gravity of the user is moved posteriorly, and the wheelchair frame is placed in a backward tilt with subsequent toe-out of the rear wheels and a positive caster-inclination angle and caster trail distance.⁵ Overall, it was concluded that many items need to be compensated for when changing the camber of a wheelchair, in order to maintain safety and efficiency of propulsion. A subsequent study focused on the effects of rear wheel camber and wheelchair stability.⁶ This study revealed an increased incidence of posterior instability but decreased instances of lateral instability with rear wheel camber.⁶ Along with the increased lateral stability is the increase of the overall width of the wheelchair, which can become a problem to those users who need to maintain an overall narrow width for mobility in tighter spaces. To compensate for the potential increased rear instability, one can utilize antitip devices as a user is starting to use camber as well as altering the rear axle placement to increase stability lost from increasing camber.

The effect of wheelchair backrests on function has also been studied. A study by May et al looked at the effect of three different backrest options on four functional wheelchair tasks (pushing up a ramp, pushing on linoleum floor, forward reach, and distance of one stroke on carpeting).⁷ The only significant difference between three different backrests was found in the reaching activity. One increased the reaching ability, and was preferred over the standard upholstery and another popular backrest. Since this study has been published, many backrests have been introduced to the market and no one backrest can work for all of our clients. A solid backrest or adjustable tension upholstery should provide better lumbar spine support compared to standard backrest upholstery, which tends to sag over time and promotes a posterior pelvic tilt or kyphotic posture.

As with all modifications, components, and accessories, there are positives and negatives that must be prioritized for each end user, specific to their needs. The table below lists many different types of wheelchair components, their intended purpose, and the positives and negatives that must be considered based on each individual’s needs and function.

Robert Meehan, MSTP, ATP, and Robin J. Skolsky, MSPT, are therapists at Shepherd Center, Atlanta.

REFERENCES

DiGiovine MM, Cooper RA, Boninger ML. User assessment of manual wheelchair ride comfort and ergonomics. Arch Phys Med Rehabil. 2000;81:490-4.
Beekman CE, Miller-Porter L, Schoneberger M. Energy cost of propulsion in standard and ultralight wheelchairs in people with spinal cord injuries. Phys Ther. 1999;79:146-158.
Parziale JR. Standard v lightweight wheelchair propulsion in spinal cord injured patients. Am J Phys Med Rehabil. 1991;70:76-80.
McLaurin CA, Brubaker CE. Biomechanics and the wheelchair. Prosthet Orthot Int. 1991;15:24-37.
Trudel G, Kirby RL, Bell AC. Mechanical effects of rear-wheel camber on wheelchairs. Assist Technol. 1995;7:79-86.
Trudel G, Kirby RL, Ackroyd-Stolarz SA, Kirkland S. Effects of rear-wheel camber on wheelchair stability. Arch Phys Med Rehabil. 1997;78:78-81.
May LA, Butt C, Kolbinson K, Minor L, Tulloch K. Wheelchair back-support options: functional outcomes for persons with recent spinal cord injury. Arch Phys Med Rehabil. 2004;85:1146-1150.

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April 2005