Solving Complex Seating Clinic Challenges in an Intense Climate

Size: px

Start display at page:

Download "Solving Complex Seating Clinic Challenges in an Intense Climate"

Matilda Drusilla Berry
5 years ago
Views:

1 Solving Complex Seating Clinic Challenges in an Intense Climate Meredith Budai, PT, DPT, ATP/SMS Sarah Murdoch, PT, DPT, ATP Colleen Smith, PT, DPT, ATP

2 Disclosures We have no conflict of interest to disclose

3 Objectives Describe two advantages of utilizing a functional mobility evaluation when prescribing and justifying a wheelchair. Identify three outcome measures to assess fall risk in ambulatory patients and two outcome measures utilized to justify need for power assistance for use when pursuing wheeled mobility. List three ways in which local coverage determination impacts eligibility for complex rehabilitation technology. Compare the individual roles of the seating team including the therapist, patient, and durable medical equipment provider, and describe 3 differences between each.

4 CRT: What makes it so complex?? Patient understanding of process Rules, Regulations, Timelines Lots of involved players Status: It s complicated!

5 What Is The Seating Team? Clinical Team Physician Therapists Other Specialists (Orthotic Team) Seating Team Seating Industry Supplier Manufactures Patient s team Patient Caregivers Payers

6 Roles Of The Seating Team Patient Identify goals, articulate needs, decision maker Physician Evaluate and document mobility needs Therapists Examine, evaluate, trial products, document Supplier Demo products, measure, home assessment Manufacturer Provide demo equipment, configure set up Caregiver Support patient, undergo training, identify limitations Payer Review documentation, provide funding

7 Seating Clinic Challenges Rules, Requirements, Guidelines Conflicting Recommendations Funding Patient Understanding Documentation

8 Challenges: Rules, Requirements, and Timelines Medicare Rules Other Payers Timelines Local Coverage Determination

9 Challenges: Conflicting Recommendations Physician documentation of function Physical and Occupational therapy goals and documentation of function Orthotics team

10 Challenges: Funding Medicare In-home rule Power seat functions Progressive diagnoses 5-7 year life of equipment Alternative funding for upgrades

11 Challenges: Funding Medicaid Alternate funding restrictions State rules Other Insurances Beginning to follow Medicare guidelines Home Health Services Billing restrictions

12 Challenges: Understanding The Process Patient Expectations: It will be quick It will be funded It will be an easy transition Clinician Knowledge/Experience: Clients may have little to no experience with wheeled mobility Client may be overwhelmed with options Client may feel limited by options

13 Physician Guide to Seating Clinic

14 Physician Guides for Clinic

15 Physician Guides for Clinic Repairs or Modifications to Current Wheelchair 1) Necessary if chair is less than 5 years old, as patient will not qualify for a new chair unless: a. There is a new diagnosis (cannot be a change or progression of current diagnosis) b. There is a significant weight gain c. Growth in a child 2) Medical appointment must document that the patient was evaluated and/or treated for a condition that supports the need for the wheelchair a. Unlike power, the primary reason for the visit does not have to state mobility examination. b. However, the documentation does need to demonstrate support for the need of a w/c (i.e. UE and/or LE paralysis, non-functional ambulation, etc.)

16 Functional Mobility Evaluation Advantages: 1- All supportive documentation in one placeincluding all outcomes measures 2- Systematic evaluation

37 Objective Measures Necessary to document the following: Need Safety Change

38 Objective Measures Measures used to justify fall risk/decreased endurance in ambulatory patients: Berg Balance Scale A 14-item objective measure designed to assess static balance and fall risk in the adult population. 10 Meter Walk Test Assesses walking speed in meters per second over 10 meters. 6 Minute Walk Test Assesses distance walked over 6 minutes as a submaximal test of aerobic capacity/endurance

39 Objective Measures Measures used to justify fall risk in ambulatory patients (continued): Timed Up and Go Assesses mobility, balance, walking ability, and fall risk in older adults Standing Functional Reach Assesses a patient's stability by measuring the maximum distance an individual can reach forward while standing in a fixed position. The modified version of the FRT, requires the individual to sit in a fixed position. Dynamic Gait Index An 8-item objective measure designed to assess balance during ambulation and fall risk in adult population.

40 Objective Measures Measures used to justify need for power: Upper extremity strength scores Borg RPE Scale A quantitative measure of perceived exertion during physical activity. 6-Minute push test Assesses distance propelled over 6 minutes as a sub-maximal test of aerobic capacity/endurance Power Mobility Wheelchair Skills Test Wheelchair User Shoulder Pain Index (WUSPI) A Scale to measure shoulder pain in wheelchair users Functioning Everyday with a Wheelchair (FEW) A self-report questionnaire administered to consumers of wheeled mobility, as an indicator of perceived user function related to wheelchair/scooter use

41 Objective Measures Other measures used to justify need for complex rehabilitation technology: Spinal Cord Independence Measure (SCIM) Walking Index for SCI II (WISCI II) Wheelchair Skills Test SF-36 Functional Mobility Assessment (FMA) Multiple Sclerosis Scales ABC Balance Test Pain Scale

42 Case Study - One 60 year old female, diagnosed with C2 AIS D secondary to traumatic spinal cord injury Previously able to ambulate in the community, however declining in ambulatory function Multiple falls, one in the middle of an intersection Requires assistance of another to transition back to standing after fall Home ambulation also declining, with multiple falls to the floor per month, uses furniture for assistance Difficulty getting out of chairs Work part time, requires assistance of coworkers to enter/exit the building and navigate the office spaces

43 Case Study - One Objective Measures First Appointment: None performed Objective Measures Second Appointment: Timed Up and Go seconds with bilateral canes A score of greater than of equal to 14 has been shown to indicate a high fall risk.

44 Case Study - One Berg Balance Scale Interpretation: 19/56 = High fall risk Sitting to standing 2 Standing unsupported 2 Sitting unsupported 4 Standing to sitting 2 Transfers 2 Standing with eyes closed 2 Standing with feet together 2 Reaching forward with outstretched arm 0 Retrieving object from floor 1 Turning to look behind 1 Turning 360 degrees 1 Placing alternate foot on stool 2 Standing with one foot in front 0 Standing on one foot 0 Total Score 19

45 Case Study - One Objective Measures Third Appointment: Activity-Specific Balance Confidence Scale Patient reported 90% confidence with reaching at eye level, 50% for walking to a car in the driveway and getting into vehicle, and 10% for walking across a parking lot, up/down a ramp and crowded mall. 6 Minute Walk Test» Patient reported 0% for remainder of questions Bilateral Canes At 63 feet patient lost her balance and only regained balance with use of wall due to lower extremity spasm. Patient ambulated with decreased step length and swing clearance bilaterally. This distance is not functional in her home setting and she reports bowel/bladder accidents and falls secondary to ambulation decline.

46 Case Study - One Berg Balance Scale Interpretation: 16/56 = High fall risk Sitting to standing 2 Standing unsupported 3 Sitting unsupported 3 Standing to sitting 2 Transfers 2 Standing with eyes closed 1 Standing with feet together 0 Reaching forward with outstretched arm 0 Retrieving object from floor 1 Turning to look behind 1 Turning 360 degrees 1 Placing alternate foot on stool 1 Standing with one foot in front 0 Standing on one foot 0 Total Score 16

47 Case Study - One Objective Measures (continued): Spinal Cord Injury Measure (SCIM) 67/100 Patient requires increased assistance or assistive devices for mobility, self cares, bathing/dressing at this time. Functional Mobility Assessment Completion of this assessment revealed that the patient s current means of mobility does not allow her to carry out her daily routine as independently and safely as possible. She reports that it does not meet her health needs as she reports she always feels like she is going to fall and has experienced multiple falls. She is not able to carry out tasks at different surface heights, carry out personal care tasks and getting around indoors.

48 Case Study - One Started process for scooter in Fall 2013 Denied twice, appeals written both times Physician note stated limited in community distances in 2015 evaluation Approved Fall 2016

49 Case Study - Two Patient is a 26-year-old female diagnosed with Sturge-Weber syndrome, epilepsy, right hemiparesis, and history of mood and cognitive issues (which had been exacerbated when she had medication changes). Patient experiences significant fatigue when walking in the community, resulting in regular losses of balance. Patient avoids walking due to fear of falling. Referred to seating clinic for community mobility recommendations.

50 Case Study - Two Objective Measures: Berg Balance Scale Dynamic Gait Index 10 Meter Walk Test Borg RPE Scale

51 Case Study - Two Berg Balance Scale Interpretation: = Low fall risk Sitting to standing 4 Standing unsupported 4 Sitting unsupported 4 Standing to sitting 4 Transfers 4 Standing with eyes closed 3 Standing with feet together 3 Reaching forward with outstretched arm 3 Retrieving object from floor 4 Turning to look behind 4 Turning 360 degrees 2 Placing alternate foot on stool 2 Standing with one foot in front 0 Standing on one foot 3 Total Score 44

52 Case Study - Two Skill Dynamic Gait Index Score Gait (level surface) 2 Change in gait speed 2 Gait (horizontal head turns) 2 Gait (vertical head turns) 3 Gait and pivot turn 2 Step over obstacle 3 Step around obstacle 3 Steps 2 TOTAL SCORE: 19/24 Interpretation: Scores < 19 are related to increased incidence of falls in the elderly.

53 Case Study - Two Results (in seconds) 10 Meter Walk Test Results (in m/sec) Assistive Device Bracing None None Interpretation of Gait Speed: m/s = limited community ambulatory.

54 Case Study - Two BORG RPE: 15 after completion of walking tests.

55 Case Study - Two Recommendations: Go-Go Elite Traveller 3WH Scooter The patient does not require a manual wheelchair and she cannot achieve functional independence with a manual wheelchair due to reports of UE weakness and overall fatigue. The patient requires power mobility to prevent fatigue, increase safety and independence for mobility within the community, and to increase her quality of life. She does not have seating system needs at this time and as such a scooter is anticipated to be the optimal choice for this patient.

56 Case Study - Two Results: Denied: Per her insurance policy she does not meet criteria to receive a mobility device as she is not bed bound. She is ambulatory in the home; however, is at great risk for falls. Peer to peer completed by physician and the scooter was approved.

57 Case Study Three 59 year old female, diagnosed with T10 AIS C Paraplegia, secondary to traumatic T8 to T12 vertebral compression fracture from an accidental fall down the stairs and subsequent medical/surgical errors. History of: Carpal Tunnel Syndrome at the (L) wrist DeQuerven s at the (R) thumb. Edema at bilateral ankles and feet Documented in her medical history and is relieved with elevation of the LEs Shoulder pain with minimal activity

58 Case Study Three Social Factors Primary caregiver of husband who has medical needs Primary Driver for family Required to perform all household chores

59 Case Study - Three Outcomes Measures 6 minute propulsion test: Documented patient unable to perform due to significant shoulder pain SCIM Unable to perform self-catheterization without recline in chair Pain ratings Successful trials of Power mobility

60 Case Study - Three Goal: Justify transition from Manual to Power mobility Power Pain and UE dysfunction aggravated by manual wheelchair mobility Safety concerns with transfers and ADLs with shoulder pain Required independence for meal preparation and iadls Power Tilt and Recline Required independence with Pressure Relief Required independence with self-catheterization Limit number of transfers per day (necessitating cathing from chair) Power seat elevate Decrease shoulder burden for transfers Independence in iadls in kitchen

61 Case Study Three

Case Study - Four 17 year old girl with quadriplegia, cerebral palsy, normal mental status Progressive Scoliosis, resistant to conservative management

62 Case Study - Four 17 year old girl with quadriplegia, cerebral palsy, normal mental status Progressive Scoliosis, resistant to conservative management Posterior spinal fusion T1-sacrum Resultant loss in strength in upper extremities Spinal fusion revision performed Tracheostomy placed, ventilator in use

63 Case Study - Four Posture Prior to surgery: Severe scoliosis right rotational component right rib hump posteriorly left shoulder elevation asymmetry throughout rib cage. Following surgery: residual throacolumbar scoliosis right pelvic obliquity slight right rotation

64 Case Study - Four Seating Independent Power wheelchair user Prior to surgery: custom molded backrest New backrest: denied by insurance Appeal Approved after peer-to-peer review

65 Case Study - Five Patient is a 17 year old female who presents with L2 AIS C paraplegia secondary to onset of transverse myelitis on April 20, Prior to the onset of her illness, patient was an active and healthy individual, involved in cheerleading. Utilizes a manual wheelchair as her primary means of mobility. Patient was referred to seating clinic for pressure mapping (due to history of skin breakdown) and for a Smart Drive assessment. Goal: Justify a new cushion and the need to transition from manual to manual with power assistance.

66 Case Study - Five Peak Pressure (mmhg): Average Pressure (mmhg): Personal Comfort Curve Comfort Company M2 with right pelvic obliquity wedge Comfort Company M2 without right pelvic obliquity wedge Varilite evolution with air removed Varilite evolution without air removed The patient pressure mapped best on the Comfort Company cushion, without use of the pelvic obliquity wedge. We discussed the risks of sitting with a pelvic obliquity, but agreed the patient has likely finished growing and is actively involved in therapies, including stretching her muscles to prevent further or fixed asymmetries. Due to history of skin breakdown the patient benefits from a set up that optimizes pressure distribution.

67 Case Study - Five 6 Minute Push Test without Power Assist 1717 feet Pre-Test Pain Post-Test Pain Pain 0/10 Pain 0/10 Borg Scale 0 Borg Scale 3 RPE 6 RPE 9 6 Minute Push Test with Power Assist (Smart Drive) Pre-Test Pain Post-Test Pain Pain 0/10 Pain 1/10 Borg Scale 0 Borg Scale 0 RPE 6 RPE 6 While using the Smart Drive the patient propelled the wheelchair 209 feet further than she did without use of the Smart Drive. This would mean, in one hour, she would propel her wheelchair 2090 feet further using the Smart Drive. Additionally, she would require significantly fewer pushes in order to complete the identified distance, and thus she would be more efficient and have minimized risk of overuse injury and pain.

68 Case Study - Six 34 year old male diagnosed with SCI secondary to gunshot, onset 2010 T12 AIS C paraplegia Bilateral carpal tunnel syndrome Pain with propulsion Pain with transfers Frame failure of manual wheelchair twice

69 Case Study - Six Social Factors Primary caregiver for 4 year old daughter Employed Full-time at an office Student

70 Case Study - Six Outcome Measures Pain- significant details Postural assessments WUSPI- 27/150 (shoulder); 128/150 (wrist) WISCI II: 0 Client is unable to stand and/or participate in assisted walking 6 minute propulsion test Grip strength assessment

71 Case Study - Six 6 Minute Push Test without Power Assist 1109 feet (4 min 47sec) Pre-Test Pain Post-Test Pain Pain 4/10 Pain 9/10 Pattern Generated Force (lbs.) Same Age Mean (lbs.) Before After 6MPT 6MPT Comments Gross Grasp Right ± Significantly decreased from Gross Grasp Left ± last OT re-evaluation in 2015, decreased by over 40lbs of force bilaterally.

72 Case Study - Six Justification Frame failure Age of seating system (5years), causing increased risk of pressure concerns/skin breakdown Improve posture Weight of current cushion Weight of client/ axel position In home ADLs Safety

73 Case Study - Six Outcomes Medicare Denied SmartDrive Awaiting Insurance approval for K0005 Manual Wheelchair

74 Case Study - Six 56 year old female diagnosed with secondary progressive Multiple Sclerosis, diagnosed with C5 AIS C tetraplegia Torn wrist ligaments Lives alone Caregiver assist for bowel and bladder care, bed baths. Dependent transfers since 2010 Full time wheelchair use in 2005

75 Case Study - Seven Seating History Permobil C500 Standing Power wheelchair (6 years old) Redman Standing power wheelchair (2 years old) Reports instability over uneven terrain Near falls in community due to instability Increased thoracic kyphosis Wound on LE from standing position Patient seating goals Have standing chairs assessed Determine which is the better chair New power standing wheelchair Repair Redman Power wheelchair to increase stability

76 Case Study - Seven Impulse purchase affected her access to new equipment Education! Comprehensive seating assessments Seating process Understand Roles

77 Case Study - Eight 59 year old male, status post resection of intramedullary ependymoma in 2002 and cerebellar atrophy in May Patient was diagnosed with fragile X tremor/ataxia syndrome and MSA. He is diagnosed with C4 AIS D tetraplegia. Multiple falls some resulting in injuries Requires assistance for all ADL s, eating, stand pivot transfers, and meal preparation Ambulates short distances with wheeled walker and assistance of caregivers Bilateral upper and lower extremity tremors with fatigue

78 Case Study - Eight Objective Measures Initial Appointment: 6 Minute Push Test feet Denied Patient propelled ultra-lightweight manual wheelchair above distance in 6 minutes. Patient had increased difficulty coordinating upper extremity movements for propulsion and performing turns. Patient had two instances of hitting objects in hallway during test requiring increased time to negotiate. Equipment for future use

79 Case Study - Eight Objective Measures Second Appointment: Six Minute Push Test feet Patient propelled ultra-lightweight manual wheelchair above distance in 6 minutes. Patient had increased difficulty coordinating upper extremity movements for propulsion and performing turns, requiring increased time to perform. Patient unable to negotiate large open spaces as demonstrated by rubbing against walls instead of ability to stay in center of large room. Finger to Nose Test During test, patient demonstrated increased dysmetria bilaterally. It took patient increased time to find the target and he missed therapists finger after touching his nose during most trials. When target was moved, patient demonstrated increased difficulty.

80 Case Study - Eight Objective Measures Second Appointment: BERG Balance Test: 13/56 CHART? Approved Patient required supervision or physical assistance through most standing tasks of this test. Patient had two loses of balance that required a second person to assist to prevent falls. Seat elevate not approved and family declined appeal process

81 Case Study - Nine 35 year old male Diagnosed with SCI, T12 AIS C paraplegia, secondary to gunshot wound Payer: Medicare Employed in Real estate, place of work 3 blocks from home Primary care giver for daughter Previous wheelchair stolen, with documented police report (TiLite Aero R)

82 Case Study - Nine 6 Minute Propulsion Test ft Seating Clinic Evaluation 2/16/2016: Patient has KAFOs, but they are not in use. He is only able to use them for therapeutic ambulation, and unable to use them without assistance of a skilled provider. Orthotic Clinic Evaluation 4/20/2016: Patient recommended for a new pair of custom KAFOs in order to participate in gait training to achieve his goal of returning to community ambulation.

83 Case Study - Nine Outcome: Denied In home restriction Community Ambulation **Importance of Team Communication**

84 Case Study Wrap Up Case Study 1 Ambulatory, inconsistent documentation Case Study 2 Ambulatory, **look up denial reason** Case Study 3 Paraplegia, manual to power wheelchair, medicare Case Study 4 Scoliosis with fusion, denial of modification Case Study 6 Power assist Case Study 7 Power assist, alternative funding Case Study 8 Progressive diagnosis Case Study 5 Impulse buy Case Study 9 Orthotics

85 REFERENCES Arledge, S., ATP, Armstrong, W., MS, RET, ATP, Babinec, M., OTR/L, ABDA, ATP, Dicianno, B. E., MD, Digiovine, C., PhD, ATP, RET, Dyson-Hudson, T., MD, Stogner, J., PT, ATP. (2011, January 26). RESNA Wheelchair Service Provision Guide. RESNA, Lin, Y., Boninger, M., Worobey, L., Farrokhi, S., & Koontz, A. (2014). Effects of repetitive shoulder activity on the subacromial space in manual wheelchair users. BioMed Research International, 2014, 1-9. doi: /2014/ Minkel, J. L. (2000). Seating and Mobility Considerations for People With Spinal Cord Injury. Physical Therapy, 80(7), Accessed July 31, Retrieved from Smith, E. M., Sakakibara, B. M., & Miller, W. C. (2014). A review of factors influencing participation in social and community activities for wheelchair users. Disability and Rehabilitation: Assistive Technology, doi: / Sawatzky, B., DiGiovine, C., Berner, T., Roesler, T., & Katte, L. (2015). The need for updated clinical practice guidelines for preservation of upper extremities in manual wheelchair users. American Journal of Physical Medicine & Rehabilitation, 94(4), doi: /phm

Functional Mobility. What does that mean? 6/26/2013. Evaluation for Seating and Wheeled Mobility

Functional Mobility. What does that mean? 6/26/2013. Evaluation for Seating and Wheeled Mobility Evaluation for Seating and Wheeled Mobility Mark R. Schmeler, PhD, OTR/L, ATP Jeannie Minkel, PT, ATP Kendra Betz, MSPT, ATP VA-Polytrauma 14 th Grand Rounds University of Pittsburgh Functional Mobility