ATP Series

Optimal Interventions for Stroke

Clients with CVA Are Often Older. Does Age Impact Their Options?

person in a wheelchair

MAN SITTING ON WHEELCHAIR: ISTOCKPHOTO.COM/KATARZYNABIALASIEWICZ

Last summer, Mobility Management published a series on the Functional Mobility Assessment (FMA), a 10-question survey for people who use wheelchairs. The FMA was developed by a team at the University of Pittsburgh; U.S. Rehab has the worldwide rights to commercialize and collect data with the FMA.

The survey has approximately 40 diagnoses to choose from. The most commonly reported diagnosis was stroke/cerebrovascular accident (CVA), chosen by 17.53 percent of respondents.

In practical terms, that means seating and mobility teams work with a lot of stroke clients. But for many stroke clients, seating and mobility intervention is a standard, attendant-propelled manual wheelchair without much ability to be fine-tuned, let alone be self propelled. Why are so many stroke patients using less functional equipment?

Anatomy of a Stroke

The Centers for Disease Control CDC) says two-thirds of people who have a stroke are 65 or older, according to 2009 statistics. In comparison, the average age for a newly injured spinal cord injury patient is 42 years, according to 2016 statistics from the National Spinal Cord Injury Statistical Center. That’s much older than the average age of a newly injured patient (29 years) in the 1970s, but still decades younger than most stroke patients.

Is a subtle form of ageism at work with stroke patients when it comes to acquiring optimal seating and mobility equipment?

The Process & the Policies

Why, for instance, are many stroke clients not given the opportunity to self propel in an ultralightweight wheelchair?

Debbie Pucci, PT, MPT, is a Clinical Specialist at Ki Mobility.

“As a clinician who continues to work in a seating clinic, I don’t feel that there’s less consideration of the ability for [stroke patients] to self propel,” she said. “However, Medicare coverage for equipment in many cases has limited the options available for individuals due to the in-the-home clause that Medicare has. That clause really limits the definition of what Medicare deems medically necessary for those individuals.”

To qualify for a wheelchair purchased by Medicare, a beneficiary needs to meet the medical necessity guidelines laid out by Medicare: “There has to be some mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living,” Pucci said, such as toileting, feeding or dressing in the home. “That’s the first criteria. Then you have to say that beneficiary’s limitations cannot be shown to be resolvable through the use of an assistive device such as a cane or walker. You have to go down that road to get them to qualify for any manual wheelchair. To qualify for what we consider complex rehab technology, that ultralightweight chair, the individual’s got to be a full-time user, and there has to be some fitting or feature about that ultralightweight, adjustable chair that cannot be accommodated by a lower-level piece of equipment.”

Once the seating and mobility team has qualified a stroke client for a standard manual chair — K0001 through K0004 — there is a decision to be made. Yes, these wheelchairs can work in the client’s home. But is there a better, more functional answer, at least for some stroke clients?

Taking medical justification to the next level can be a lot more work. Given the busy days of clinicians and ATPs, is a possibly modest improvement to a client’s functionality worth the amount of effort it would take to justify a more fully featured chair?

Curt Prewitt, MS, PT, ATP, is Ki Mobility’s Director of Education, and he acknowledged, “Some folks are much more comfortable getting down to that greater level of detail and really fleshing out that justification, and some folks, frankly, might have a little bit harder of a time, feeling like maybe they’re asking for too much. They see it maybe as a significantly tougher fight to try to convince [the payor] for what might seem to be just a little more benefit.”

Linda Bollinger, PT, ATP, DPT, Clinical Education Manager at Sunrise Medical, said stroke patients’ environments can also play a role in the equipment they receive.

“I feel as though the self-propelling manual wheelchairs are less considered for the elderly/stroke patients due to two basic reasons: opportunity and process,” Bollinger said.

“When we think of the opportunities for the elderly/stroke patient to be assessed for self-propelling manual wheelchairs, we must consider the location of the client. For example, if the patient resides in a nursing home, the nursing home is responsible for providing the wheelchair as part of the nursing home rate. Therefore, the patient is generally given a wheelchair from the ‘equipment closet.’ This closet is often stocked with standard wheelchairs that can be assigned to any resident.”

While therapists do their best to fine-tune such chairs to their clients’ individualized needs, Bollinger said, “Self-propelling may not be a consideration, especially when the goal is finding a method to get the individual out of bed safely. In addition, because [therapists] are using standard equipment, they are unable to ‘optimally configure’ the wheelchair using components such as adjustable wheel axles and seat angles.”

Bollinger added that discharge teams who order equipment for stroke patients preparing to leave the hospital “may not necessarily include a seating and mobility specialist. The patient will generally have Medicare as primary funding. The discharge team is usually more familiar with the standard equipment (competitive-bid products) versus complex rehab technology products. Again, this limits the consideration of self-propelling manual wheelchairs.

“If the patient is fortunate enough to be referred to a therapist with seating and mobility experience, then the evaluation and funding process is what often hampers the acquisition of a self-propelling manual wheelchair. Even when the individual qualifies for a K0005 wheelchair, the individual does not always want to take the time needed to document the need. I had many patients complain about the number of appointments for the process, which includes face-to-face appointments with the doctor, therapist evaluations, equipment trials, etc. They also complain about the time the documentation process takes. Many will opt for just ‘getting what Medicare covers’ in an effort to get a wheelchair quickly and easily.”

Investing in the Details

If a stroke client and the seating and mobility team do want to pursue a more functional choice, such as a K0005, Prewitt suggested demonstrating the possibilities between a standard manual chair and a more adjustable one.

“The person can make it from the dining room table to the kitchen sink,” he said as an example. “But with [a standard] chair, they can do that one time. Does that totally fatigue them for the next four hours? Does that prevent them from being able to do the next activity of daily living (ADL)? Maybe there’s something further that could be gotten into in a greater level of detail: ‘Yes, they can do that, but then they’re too fatigued to do these other mobility-related ADLs. If we put them in different equipment, maybe something with an adjustable axle or that is fit better and a little bit more efficient, then they could do that ADL and the next one.’”

Pucci agreed: “I think that’s a valid point. When we look at lower-level pieces of equipment, we might be able to set that chair up to see improvement in one ADL at the expense of another. For instance, a lot of individuals post-CVA foot propel. Maybe we can get a lower-level chair in a hemi seat-to-floor height to allow them to get feet to the ground to foot propel. Or a lot of individuals propel with one foot and one upper extremity. But by lowering that seat-to-floor to allow effective propulsion, now that individual is not able to do their transfers. They’re not able to transition from sitting to standing from such a low level.”

The Tilt-in-Space Possibility

For some stroke clients, a manual tilt-in-space chair could offer additional functionality. And the E1161 also offers a potential advantage from a medical justification perspective.

“When you’re looking at the E1161 code,” Prewitt said, “you don’t necessarily have to go through that hierarchy of ruling out all the lesser pieces of equipment. If [the client] would benefit from a tilt-in-space chair to help them with one or more of those mobility-related ADLs, then they can qualify for that E1161 code.”

“But if you are considering the benefit of the tilt feature for an individual, you don’t have to rule out those lower-level chairs,” Pucci said. “Tilt in and of itself, if you can justify that feature as medically necessary, you do not have to rule out a lower-level chair.

“Most people, when they’re trying to justify tilt for an individual, they only think about tilt as being beneficial in providing pressure relief, as a form of pressure relief for skin protection. But there are so many other benefits to having an adjustable seat angle. Adding that little bit of seat slope can help stabilize someone’s pelvis position when they’re foot propelling or hemi propelling so they maintain good postural alignment during their mobility.”

“That’s true during static sitting as well,” Prewitt added. “That little bit of seat slope, especially [for] someone with a kyphotic posture, for example, can be helpful. If you can drop the back of their seat down just a little bit, you can stabilize their posture in that chair a little bit better. Ideally, you might bring their head up a little bit better so they have better visual access to their environment, and they can see and interact better with what’s going on around them.”

“One of the things we talk about with the ability to change that seat angle is also good head positioning for swallow,” Prewitt said. “A lot of individuals post-CVA have swallowing issues, so helping them to achieve a head position for more successful swallow could be another justification for an adjustable seat angle. That’s part of the coverage criteria: mobility-related activities of daily living, such as toileting, feeding, dressing, grooming. Feeding is specifically mentioned.”

Getting Everyone On Board

Given its additional benefits, a more fully functional chair might sound like an obvious preference for stroke clients. But that’s not always the case. Other expectations, including cultural ones, might influence the decision-making process.

For instance, when a stroke patient is older, family members might question how much additional function or independence is practical or desirable. Or family members might feel duty bound to take on more responsibility, such as pushing a wheelchair.

“But if we could get people into better equipment, ultimately how much more access and independence could we give them?” Prewitt asked. “Granted, that family member might still have to be involved with pushing that chair, at least for longer distances. But maybe inside the home, we could give them something so Mrs. Smith doesn’t have to push Mr. Smith around for as much of the day. She only needs to help him when it’s time for transfers.”

“In a lot of cultures, seniors are people that we need to care for,” Pucci said. “We need to care for Mom, we need to care for Grandpa. If they need me to get them from point A to B, that’s my duty to do that. There are a lot of cultures that perceive that.”

“That’s an admirable thing,” Prewitt added. “But the down side is if [the patient] becomes dependent on someone to do that, and even if that person feels it’s their duty and their motives are perfectly altruistic, it can sometimes be a disservice to those folks and their ability to help with their own rehabilitation.”

Bollinger would like to see a change in how the medical profession perceives stroke patients. “With the elderly/stroke patient, there needs to be an industry shift with regard to independent mobility,” she said. “Nursing home administrators/therapists must see the value of fitting more individuals with adjustable/modifiable wheelchairs as opposed to standard equipment. If we can provide independent mobility, we will not only improve these patients’ quality of life, but we can also improve efficiency in nursing homes.

“Another industry shift may be to teach family the value of independent mobility. Often the family is not focused on the individual’s independence. They might prefer a transport chair due to weight for their own ease. We know that there is a relationship between independence and perceived quality of life. Sometimes families assume that the individual is not capable of independent mobility and do not want to be inconvenienced by the process, size of equipment, transporting equipment, etc.

“Education to the patient and family needs to start at their first appointment. I discuss goals for the patient, family and therapists at intake. I explain the process including timelines for me, the RTS, approval process, ordering, etc. I also use demos to show the difference between independent mobility and dependent mobility as part of the education.”

This article originally appeared in the February 2019 issue of Mobility Management.

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