A Key to Better Outcomes?
- By Laurie Watanabe
- Jan 08, 2020
CAR KEY: DEPOSITPHOTOS/LUKATME1
If you could create the optimal team to conduct a complex rehab technology (CRT) seating and wheeled mobility assessment, who would you include?
You’d start with the client, of course, then expand to family members and caregivers, the CRT clinician, and the ATP supplier. Depending on a client’s particular needs, you might add other specialists — speech pathologists, recreation therapists, respiratory therapists, case managers, school personnel, maybe manufacturer reps.
Great! But is that everyone who should be included?
From the Very Beginning
Industry veteran Dan Allison, MS, OTR/L, ATP, can contribute to a wheelchair evaluation from multiple traditional seating and mobility perspectives.
But Allison is also a CDRS — a Certified Driver Rehabilitation Specialist, a credential awarded by the Association for Driver Rehabilitation Specialists (ADED) — who has headed the training department at Shepherd Center’s Adaptive Driving Services Program in Atlanta. And he sees real value in including adaptive automotive specialists in the wheelchair eval process.
Allison said vehicle transportation should “absolutely” be part of the overall wheelchair accessibility discussion from the very start, just as the client’s home should be assessed to be sure the chosen wheelchair — particularly if the client will be driving a power chair — can maneuver well inside.
Of the transportation assessment, Allison said. “It doesn’t have to trump what goes on in the house [assessment]. I don’t think you have to make [the wheelchair] fit the car. It has to be the best of both worlds. Home is probably first priority, but I sure hope they don’t disregard getting into a vehicle.”
The most common incompatibility, Allison added, is “the dimensions of the wheelchair versus what vehicle they’re going to be using. Some vans have greater door entry heights now; before, it was so sad because a church would buy the van before the person even got the wheelchair, and they’d get the wheelchair, and the wheelchair wouldn’t fit in it.”
Another potential problem even in vehicles with more headroom is the combined height of power chair and user when driving up a ramp into the vehicle. “If they tilt back, they run the risk of not being able to move forward at the same time,” Allison added. “Plus when they get in the van, they can’t pivot because their feet are sticking out so far, and it’s a convoluted circle.”
Vehicle doorway widths are usually less of a problem: “The narrowest are around 30", and most are a little bit more than that,” Allison said. “The problem might come if the arm supports are in the way,” such as if the armrests are set wider than the footprint of the wheelchair base.
When working with bariatric clients, the team also needs to consider the weight of the client plus the chair, versus what the automotive equipment and the vehicle itself can accommodate. “Some of these chairs, with the client in them, are pushing 800 lbs.,” Allison said. “You have to be careful of the weight requirements, not only of the ramp of the van — most newer ones are 800 lbs. to 1,000 lbs., but some older ones are only 600 lbs. — but a lot of modified minivans only have a payload capacity of around 1,100 lbs. So if you use that up with 800 lbs. for the disabled person [and the power chair], that only leaves them with 300 lbs. for cargo and other passengers. Quite often, [vehicles] are overloaded.”
Inside the vehicle, maneuvering will be required to get the power chair user to the desired location. “A lot of times, it’s easier if they can back up the ramp if they’re going to sit in the right front area as a passenger,” Allison said. “This gives them some maneuvering room. And if they’re going to be a passenger, a lot of times they will have someone to help them get in and out of the van. That makes it easier.”
A power chair user who is driving the vehicle often will use “an electronic docking device so they can independently secure themselves.” In fact, among the first transportation questions to ask, Allison said, “is can they transfer and tote the wheelchair with some other method?” and whether transfers will be done independently. Even if wheelchair users can transfer independently, will they need help stowing and securing the empty wheelchair if wheelchairs are coming along for the ride?
“There are quite a few products on the market to help with transfers,” Allison said, “without going to a ramp van.” If the power chair is coming along, many consumers assume that a scooter-style carrier mounted to the back of the car will suffice.
“Most rehab chairs aren’t going to fit,” Allison said. “Not if you have a rehab seat.”
Given everything that needs to be discussed, Allison said having a CDRS as part of the assessment team would be “the ideal scenario. Best-case scenario is having the funding source there as well, and the [wheelchair] vendor. But that doesn’t happen very often.”
Bringing Everyone Together
To benefit from the most complete assessment team, Allison recommended having both a CDRS and a mobility dealer present.
“Not all CDRS’s are going to be comfortable [with recommending equipment] because not all of them work with wheelchair drivers,” Allison explained. “Hopefully, they know who to hand off to, in that case.”
Adding the mobility dealer would bring automotive equipment expertise to the team. Just as the ATP supplier makes seating and wheelchair recommendations while working with the seating and mobility clinician, the mobility dealer makes recommendations based on what the CDRS and the dealer have observed.
Mobility dealers are the ones typically most familiar with weight capacities and vehicle measurements, for example.
And really, the scenarios previously mentioned are just the start. If the client uses a ventilator, for example, and the power chair includes a vent tray — not only does that equipment change the dimensions of the chair, but “can the vehicle modifier put a system in the van so [the ventilator] isn’t draining the wheelchair [batteries]?” Allison asked.
Making the vehicle larger to fit a larger wheelchair isn’t always an elegant solution, either: “In order to get the higher door height, like a 57" height with 14" lowered floors, they raised the entire body 4",” Allison noted. “So the van they used to drive into their garage, now they go home and it no longer fits. There are a lot of environmental concerns.”
A common saying in complex rehab is that no two seating and mobility systems are exactly alike, even among clients who have very similar diagnoses. The same can be said for their transportation needs. Some will drive the cars, while some will ride as passengers. Some will transfer; some will ride in their secured wheelchairs.
“Just because somebody has a Toyota van, that doesn’t mean it’s the same as the last Toyota van you had,” Allison added. “It’s important for the family to know what their financial situation is going to be. If they don’t have the funding, that changes everything. You can’t get them the ideal situation, so we have to do the best we can with what they’re able to get.”
Privately owned vehicles are only the start of the discussion. Will the wheelchair user also ride in subways, trains, school buses, or paratransit vehicles? “Private paratransit companies are getting better all the time,” Allison said. “But quite often, they were trained by the person who did the job before them, so it gets watered down by two or three people, and they just push the people in the van without any proper securement training. It’s getting better, but the education need is so huge.”
This is the first in a series on the connection between and convergence of complex rehab technology and accessibility.
This article originally appeared in the January/February 2020 issue of Mobility Management.
Laurie Watanabe is the editor of Mobility Management. She can be reached at firstname.lastname@example.org.