The Right Fit

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August/September 2003

By Carol Daus

William C. Miller, PhD, OT, assists a client, Helen, in an ABC Scale activity, reaching for an object on tiptoes. Achieving repeated success in activities such as this leads to increased confidence.

Bariatric clients’ specific needs have created a market of mobility options.

As the obesity rate continues to rise in the United States, the demand for bariatric seating and mobility services has grown dramatically. Manufacturers have responded to this market segment by offering both manual and power wheelchairs specifically designed for obese patients. Ten years ago, it was a challenge finding a wheelchair with a 600-pound load capacity; now most manufacturers carry these products and several even have wheelchairs with 1,000-pound load limits.

Therapists are also seeking out specialized information to assist them in prescribing the appropriate wheelchairs for their bariatric patients. Michael Dionne, PT, owner of Gainesville, Ga-based Choice Physical Therapy and a well-known bariatrics expert, has seen a sharp increase in attendance for his seminars, which cover seating mobility, as well as safety concerns related to transfers. “I didn’t have much of an audience until the last couple of years, but now there’s a huge demand for the program,” says Dionne, who instructs more than 200 rehabilitation professionals and nurses each week.

Jean Minkel, PT, a seating specialist based in New Windsor, NY, who has been in the business for 20 years, notes that she has seen a fairly large increase in the number of people fitted for bariatric wheelchairs whose primary disability is morbid obesity. “Even if these individuals have osteoarthritis, cardiovascular disease, or some other condition, obesity is the major reason they need the wheelchair,” says Minkel. She says a smaller, yet growing group of bariatric wheelchair users have preexisting disabilities, such as spinal cord or head injuries. As these individuals get older, their shoulder and elbow joints start to wear out due to years of constant wheelchair propulsion, which causes them to switch to power wheelchairs to prevent pain and discomfort. “Since they aren’t burning the calories they used to burn from propelling a manual wheelchair, they often gain weight.”

Dionne concurs that geriatric bariatric clients represent a relatively new patient population. “In working with these people, you have to consider factors such as oxygen dependence, orthopedic deformities, and poor endurance from heart failure.” Dionne adds that he is also seeing an increase in pediatric bariatric clients as obesity rates rise in children.

Wheelchair Prescription
Bariatric seating specialists agree that one of the most important considerations in selecting the appropriate bariatric wheelchair is to respect the diversity of the obese population in terms of size and body shape. Soft tissue accumulation and weight distribution vary among bariatric patients. A person may have a pear shape, which indicates gluteal-femoral obesity, or an apple shape, which shows abdominal obesity, and there are subgroups within each of these two major groups. The person’s height also dictates the height of the chair.

“The best way to determine which chair is appropriate for a patient is to get them on a solid surface such as a therapy mat or firm plywood and measure them,” says Dionne. “The goal is to simulate the posture they will have in a wheelchair.”

Minkel points out that bariatric clients cannot be fitted in the same way as nonbariatric clients. For the average-weight person, the width of the chair is determined by a hip-to-hip measurement. “With bariatric patients, you need to think in 3-D and determine where the skin folds and pockets are,” explains Minkel. For most wheelchair users, the seat depth would be determined by measuring from the back of the buttocks to the back of the knee. However, if the bariatric patient has excess tissue surrounding the buttocks, a seat to accommodate this tissue would cause their upper trunk to lean back, which would then need to be supported with a backrest. One manufacturer has even designed a bariatric wheelchair with a shelf in the back of the seat to accommodate this redundant soft tissue.

Michael Dionne, PT

According to Barbara Crane, PT, ATP, a researcher in the Rehabilitation Science and Technology Department at the University of Pittsburgh, particular attention should be paid to an individual’s medical history and plans for surgical intervention. “If an individual is going to have a gastric bypass, they will lose a lot of weight quickly and the equipment will need to accommodate this change,” says Crane. Most therapists recommend that rental equipment should be used in these situations until the person’s weight stabilizes.

If an obese person is determined to use a manual wheelchair, a realistic assessment of their abilities should be conducted. This should include a recording of the maximum distance a person can propel, the type of floor surfaces involved, and the time it takes to propel that distance. Assessing the client on ramped or pitched surfaces, as well as outdoor surfaces, is also helpful to determine the potential for manual mobility.

Crane encourages her bariatric clients to try powered mobility even if they are certain they want a manual wheelchair in order to feel the differences of the two experiences. “Many bariatric clients—and sometimes their physicians and other health care providers—think a manual wheelchair is the perfect way for them to exercise,” says Crane. “It’s important for them to know that wheelchairs are not exercise devices and that they are better off with a proper mobility system and an alternative plan for getting exercise into their days.”

Home Environment
The home environment is an important consideration in selecting a bariatric wheelchair. “Every effort must be made to keep the equipment as small as possible while still meeting the person’s needs in order to get through doorways and rooms and onto van lifts,” explains Crane. Most bariatric wheelchairs require a 34-inch or more door width. Open space should also be available in an area to accommodate a walker or a mechanical lift device, as well as the wheelchair.

Floor coverings are another factor, particularly if the person is using a manual wheelchair. A floor with no carpet is ideal; even low pile carpet or indoor/outdoor-type carpeting could present problems.

Because mobility inside the home is a primary goal, seating specialists should make home visits before prescribing a wheelchair. If clinicians are not reimbursed for home visits, a manufacturer’s representative can be sent to the home to determine if a chosen product is adequate.

Minkel points out that if a bariatric client is marginally ambulatory in the home, there are more options because they can use a walker to get through inaccessible doorways if necessary. Architectural barriers, however, are a real challenge for the morbidly obese. Minkel relates cases in which doors had to be widened and floors reinforced to accommodate the equipment.

Improvements in Design
As the bariatric market has grown, manufacturers have made many improvements in their bariatric wheelchairs, particularly in terms of durability and adjustability. In the past, bariatric wheelchairs were simply oversized standard chairs; today they are designed to be both durable and user-friendly.

Manufacturers have also increased the weight capacity of their regular wheelchair to 300 pounds, which is adequate for many moderately obese individuals. Clients with weights over 300 pounds are usually fitted for a bariatric wheelchair.

Minkel notes that the newer power chairs, which house the electronic mechanism below the seat, have benefited the bariatric population because a larger seat can be placed on top. “I recommend these because you can get an overall narrower profile, but it still meets the seating needs of an obese person, compared to a manual chair in which the wheels are outside of the seating surface, creating a wider profile,” she says.

Dionne adds that the newer bariatric chairs allow clients to adjust the width and depth, and remove backrests. A tilt-in-space position is also available for bariatric patients with strong endurance for dynamic activity. In recent years, manufacturers have replaced air in the tires on many bariatric wheelchairs with solid urethane or other durable materials, which require less maintenance.

Reimbursement Issues
As bariatric equipment becomes more costly, reimbursement is a problem for some clients, particularly those individuals who are obese but do not appear to have a medical necessity. “It is often a struggle to get power equipment paid for if the person does not have a specific upper extremity disability,” explains Crane. “Payors do not seem to understand the limitation in using manual wheelchairs for someone who weighs 400+ pounds even if they have ‘normal’ upper extremities,” she says.

In many cases, patients are denied power bariatric wheelchairs and health care providers become very involved in a lengthy denial process. Crane believes therapists should be more proactive in providing justification for the need of this equipment and should be willing to keep appealing to the payor if the claim is denied. “Having a picture or video that shows how a client has difficulty propelling a manual wheelchair can make a difference in receiving adequate reimbursement for a power chair,” she says.

It also helps if in the claim the therapist describes the benefits of a bariatric chair, such as a better suspension system that can withstand heavy loads for a long period of time. Some payors are unaware that a bariatric chair is a cost-effective, long-term solution for obese individuals. Improper wheelchair prescriptions can result in unnecessary replacement costs when an inappropriate nonbariatric chair has been substituted for a bariatric chair.

Dionne notes that an effective strategy for obtaining adequate funding for power mobility is to convince the payor that the wheelchair will restore function and decrease health care costs. “If a wheelchair can help a person propel at work or in the community to decrease their dependency on home care and other medical services, this justification can be used to receive sufficient reimbursement,” says Dionne. Although funding is a problem for most HME equipment, some therapists point out that a growing number of private payors and Medicare recognize that overweight people need more expensive seating and mobility equipment for safety precautions.

Crane expects the bariatric seating market to grow in the years ahead due to new medical interventions that are helping improve the quality of life for morbidly obese people. “More medical management has been leading to exposure to rehabilitation, which leads to assessments for appropriate assistive devices, unlike in the past when most obese people would have stayed in their homes, often in bed, without any intervention,” she says.

“Technology is available now that can help them,” she adds. “And this technology continues to keep improving.”

Carol Daus is a contributing writer for Rehab Management.

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