ATP Series

Tilt & Recline: One Client's (& ATP's) Story

• By Laurie Watanabe
• Nov 01, 2014

In her complex rehab technology career, Stephanie Tanguay, OTR, ATP, has worked as a clinician, a provider and now, as a clinical education specialist for Motion Concepts. Her tenure has enabled her at times to follow clients’ progress through the years and interact with them while in different professional roles.

Tanguay, who’s based in Detroit, says that when the subject of using tilt and recline together comes up, she remembers a client she worked with intermittently for years — a man who sustained a C6 spinal cord injury (SCI) in a motor vehicle accident in the late 1980s. For this story, we’ll call him Ted.

At that time, Tanguay was working as a clinician.

“He was an engineer for one of the automotive companies here in Detroit, and when he received his first power chair, it was a power chair with full power recline,” she says. “He used it successfully: We had the back that goes down, the legs that can come up, and it worked and served the majority of his purposes to a point.”

Heterotopic Ossification Complications

Unfortunately, Ted suffered a complication that’s well known in conjunction with SCI. He developed heterotopic ossification, described by the National Institutes of Health as “the presence of bone in soft tissue where bone does not normally exist.”

“This gentleman developed heterotopic ossification in his hip joint — both of them, but really severe on one side,” Tanguay says. “Maybe three years post injury, his son was helping him with some passive range of motion at home and hit that end of range. He pushed past it a little bit, assuming it was just a little spasticity, and broke [Ted’s] leg — for the first time. Over the course of the next 20 years, this gentleman sustained several lower-body fractures, whether it be from jamming his leg against a wall with a really bad turn in a hotel room while he was in his power chair, to somebody transferring him using a lift system and not being really careful.”

Losing bone density after years of not bearing weight on his lower extremities made Ted’s bones more brittle; the heterotopic ossification made things worse.

“One of the problems with heterotopic ossification is he had a pretty significant limitation,” Tanguay recalls. “He could not flex to 90°. When he was sitting in his power chair, he could go into full recline, but the actuator would close the back angle beyond the point where he had range of motion. And when that scenario happens and you get to the end of the range for the joint, as the back continues to close, that force against your posterior pelvis moves your buttocks anterior — forward on your cushion surface. So it creates a shear force on your seat. It’s shoving your buttocks forward.

“So he had a spinal cord injury, heterotopic ossification, a range-ofmotion limitation… and then he develops a pressure sore.”

Fighting for a New Intervention

Those conditions together, Tanguay says, created a spiral.

“It wouldn’t be right away, but he’d be in this long loop where he’d end up with a pressure sore inevitably, then [Ted’s insurance company] would pay for a lot of wound care and nurses in the home, and then he’d be fine for awhile, and then this would happen again,” she says.

Through that time, Tanguay estimates Ted went through three power chairs, “and all of them were done exactly the same: power base, power recline. Power base, power recline.”

When Ted needed his next power chair — 15 or more years post injury — Tanguay was working as a complex rehab provider. Because Ted was still having skin breakdown, Tanguay says that when his seating & mobility team discussed possibilities, “I said, ‘I really think this guy is an excellent candidate to have tilt and recline.’”

The team submitted a claim for tilt and recline on the new chair.

“We got a rejection,” Tanguay says, adding that the rejection happened even though Ted had private insurance rather than Medicare or Medicaid coverage.

“But like a lot of insurances would, you look at this scenario, this history, and this guy’s always had power base, power recline, power base, power recline,” Tanguay points out. “Why now are you asking for power recline and power tilt? It seems excessive. This recline has met his needs for years. Are you taking advantage, are you trying to jack up your price [that the provider could charge]?”

Same Intervention, Same Result

Ted’s insurance company instead approved a power chair with power recline, the system Ted had used for years. Results were predictable.

“He got another wound very shortly after receiving the new chair,” Tanguay says.

But the insurance company then contacted the provider to ask for insight. “And we said, ‘This is why we thought that a power tilt, power recline would meet his needs better,’” Tanguay says. “They said they needed clinical documentation, so I did some pressure mapping. I took with me a power chair that had tilt and recline; I got a manufacturer’s sample that had both. And I pressure mapped him fully reclined in the system, basically simulating full recline in the chair that he had.”

Results confirmed what repeated pressure wounds had suggested.

“Pressure mapping showed that in using the power recline that he’d always used, the cushion he’d always used, in full recline with his legs elevated, this gentleman could not alleviate the pressure,” Tanguay says.

Step two: “We had him recline and then tilt, and we didn’t have to tilt a lot at that point — fully reclined with about 15° of tilt.”

The mapping showed all the pressure had been relieved.

Cost Effectiveness & Quality of Life

“And so we explained that, as well as referenced a study that said heterotopic ossification puts people at risk for developing pressure sores and this is exactly that scenario,” Tanguay says. “[Range-ofmotion] limitation, displacement, or limitation and his being forced to sit in something that has a more closed angle than his body is able to achieve, and the pressure is not in a place where it can be managed.”

The insurance company approved tilt and recline. But unfortunately, the recline component couldn’t just be added to that particular chair.

“If they had spent the money to approve what had been originally recommended, it would have saved them a lot of money,” Tanguay says. “Not just because now we have to pull the recline off and put a power tilt and recline system on the base, but also the money it cost the insurance company when he got yet another sore, the wound care management, the home nursing and everything else. There are times when simply full tilt or full recline does not do it.”

Despite his multiple bouts with fractures and pressure sores, Tanguay says of Ted, “He lived a long life. He returned to work as an engineer, he retired, he traveled. But his quality of life would have been a lot better if he didn’t have to deal with wounds periodically, if he didn’t have to deal with being out of work at points when he was having those exacerbations and issues.

“I think about him a lot when I work with other patients and hear, ‘We’re not getting funding for this’ or ‘We’re not getting funding for that.’”

This article originally appeared in the November 2014 issue of Mobility Management.