Justify It: Power or Manual

When working with clients who have lower-cervical
spinal cord injuries (SCI) — think of
the C5/C6 region — clinicians and ATPs can
face a mobility crossroads.

Option 1: Ultralightweight manual mobility that’s self
propelled, typically minimalist and elegant in design and
appearance,
and significantly more capable of fitting into less
than ideally accessible environments, including cars and taxicabs.
P.S. — they’re also typically less expensive, a detail very
meaningful to funding sources.

Option 2: Power mobility, which preserves its user’s energy
(and possibly its user’s shoulders) while offering touch-of-abutton
powered positioning functions such as tilt to perform
critical weight shifts.

Which pathway is better for any given client depends on many
variables — clinical and, just as importantly, personal ones.

What Drives the Decision

Curtis Merring, OTR/L, MOT, is now a clinical education
manager for Permobil. But as a former director of rehabilitative
services, he has years of experience in assessing clients for
complex seating and wheeled mobility. Clients have included those with SCI, and those whose level of injury could have
indicated
either manual self-propelled or power mobility.

“The decision between manual and power always starts with
the person and their MRADL [mobility-related activities of daily
living] needs,” Merring said. “The process is the same regardless
of injury, but there are specific considerations that come up when
working with a person with SCI.”

He noted that two clients with the same level of SCI could opt
for different equipment choices based on other factors, including
“genetic factors beforehand, ADL demands, what do they need to
do, what do they want to do.

“We’re designing one wheelchair for one million functions, and
each time I do a wheelchair evaluation and a wheelchair design,
I’m just trying to eliminate as many trade-offs as possible.”

A Thorough Evaluation

While evaluations of clients with SCI will always include discussion
of the levels of injury and incomplete vs. complete injuries,
Merring suggested that clinical questions should be only part of
the overall conversation that helps to determine whether a client
uses manual or power mobility.

“I have an evaluation form that I put together,” he said. “[It starts with] demographics, then insurance information,
because those are pertinent, and then
diagnosis codes, because that’s going to help us
drive funding and figure out what is available
when I’m working with the ATP and insurance.
But then I’ll ask: What are your life goals? What are you
doing every day?”

Newly injured clients come to their assessments while still
adjusting to their new lifestyles; they may be full of questions.
Clients who have lived with SCI for years might be coming in
for assessment prior to ordering their second or third chairs;
they may believe they’ve already decided what they want.
Merring says the two groups need to be asked
different questions.

“For a first-time user, you have to determine
what they need to accomplish daily,” he said.
“What do they need to get done during the day?”
For experienced wheelchair users, “You have to
determine what they can accomplish in their current
system, and then what more they would like to accomplish
from a new or improved seating system. If we were to get
you a new seating system or an improved seating system, what don’t
you accomplish throughout the day that we can help you accomplish if
we applied better technology and better fitting and better posture to the
new seating system?”

Answers will vary for a lot of reasons.

“If I’m evaluating a 90-year-old woman who just wants to go
from her bedroom to the kitchen and then to watch TV, [that
mobility system] may not be something incredibly well designed
for 2,000 to 3,000 pushes a day [as you might see for] a very
active person, who works full time and is in his or her chair for
10 or 12 hours a day. You have to get that whole idea of what they
did before, what they want to be now — and how can we help
them with this new device?”

This is a major part of the assessment, Merring pointed out:
“You want to get the biggest global picture you can, so that when
you’re designing the chair, you really have an idea not just of the
physical issues with this person, but what do they like to achieve
personally?” He referred to this part of the process as a “conversation,”
one that everyone on the seating and mobility team
should contribute to.

“As the clinician, I’m the objective observer,” Merring said.
“Say Mom’s giving an opinion, and then the 18-year-old young
adult [who is the wheelchair user] is giving an opinion, the ATP is giving an opinion. It’s my job to take those parts
and try to figure out what’s optimal for this person.
Another thing I like to do — and this is why I
think multiple [assessment] visits are really
important — is maybe in the first one, everyone is
there. And then in the second one, it’s just me and
the person that’s getting the chair. Then he can say,
‘My mom says this, but I really want to do this.’”

The Mat Evaluation

After one or more conversations about goals and priorities, it’s
time for clinical observations. “I like to look at what they’re
sitting on now, and see how they propel,” Merring said. “I
need to see: What does their pelvis do, what does their spine
do, how strong are their arms, can they propel or not, how
strong are their legs? And then I seat them on the mat: What
is the shape their pelvis takes, the spine takes, the rib cage
takes, when gravity starts to take effect? If you have a very tall
[client] and a very short one, gravity may affect their thoracic
spines differently.”

Merring also uses that time to discuss aches and pains
potentially
related to self propelling.

“As I’m doing my mat assessment, if I’ve gotten a good
history, I can say, ‘I see you’ve had some minor shoulder issues
or moderate shoulder issues in the right shoulder. I’m going to
move your arm: Does this hurt?’”

Having a family member present can be helpful to this part
of the process, Merring noted, because “A lot of times, people
in chairs have accommodated for so long that they think
[discomfort] is normal. Maybe [a family member] says, ‘I see
you grimace’ or ‘Three or four times a week, you do complain
of shoulder pain when you’re going to bed.’ That extra set of
eyes can give you the data you need to help determine what this
person could use.”

Pressure Injury Considerations

Pressure injury risk is always a concern for wheelchair users,
and therefore is a critical consideration when choosing between
power and manual mobility.

“If a person wants manual mobility and they have a history
of pressure injuries,” Merring said, “I have to make sure I’m
helping them optimize their seating system so that they can
have the best cushion and the best postural support. People
sometimes forget that an open back angle can increase pressure
over the sacrum. A scoliotic curve that’s not corrected can
increase pressure over an IT [ischial tuberosity]. So the cushion
is important, the backrest is important, how they sit in their
current seat is important.

“After all that, can the person do the pressure reliefs that
they’re supposed to be doing frequently and adequately? If they
can’t, I may start leaning toward power tilt, or if they’re really
pushing for [manual], I start talking about a training program
or a maintenance program so they get some feedback. We’ll
do our evaluations with pressure mapping, and it’s
incredible that when you put a pressure map under
someone and have them lean to the right, lean to
the left and lean forward, you can see that even
without completely pushing up, you can clear all
pressure from underneath each IT just from leaning
left and right. We’ll use that for training also. If the
person really wants manual, has used manual and has
an issue with pressure relief — then after we’ve made sure
the seating system we’re going to order is optimal, we’ll use
pressure mapping for some additional training.”

Merring also observes the client’s shear risk during
the assessment.

“When I do my mat assessment, I get my initial picture of
what it’s like for this person to do a transfer,” he said. “I get a
baseline, because they’re usually transferring from one surface
to another level surface. If I see a little bit of struggle or a little
bit of drag, I may have them repeat it. And if time allows, I like
to see how they get in and out of a car, as well. Are they dragging,
are they lifting? Do we have to think about floor-to-seat
height because the car transfer is a major transfer or the toilet
transfer is a major transfer?”

SCI & MRADLs

So when the conversations have taken place, the mat eval is
finished, the pressure injury history has been considered —
what ultimately determines whether power or manual mobility is
better for a given client?

“The mobility need for people with incomplete cervical SCI
will depend upon the completeness of injury and subsequent
strength,” Merring said. “Lower cervical spine injuries will
depend upon their upper body and postural strength post injury.”

And while the power vs. manual question commonly
comes up for lower-cervical SCI, Merring said that isn’t the
only scenario.

“Something I’ve been considering more lately are people with
higher thoracic injuries secondary to the extent of compromised
postural strength and the effect that has on the shoulders during
propulsion and other issues,” Merring said. “Postural strength
is an important aspect of wheelchair propulsion that can be
overlooked. Impaired postural strength can be improved by
providing optimal positioning with ergonomic seating through
the frame, cushion and backrest. Improved postural position
improves a person’s ability to propel, allowing for someone with
compromised muscle strength to possibly propel a wheelchair if
it is optimally configured.”

A Boost from Power-Assist

In the question of power vs. manual mobility, power-assist
systems for ultralightweight chairs can offer a sort of hybrid
intervention, while possibly broadening the population of wheelchair
users who can self propel.

“Power-assist is becoming more prevalent, for good reason,”
Merring said. “I consider power-assist at every assessment, even
as low as initial injuries at T3-T4. If you think of where T3-T4
is, that’s the nipple line. Think of folding over, where you have
muscle on top and paralyzed muscle underneath: You’re kind of
folding in the middle. So postural strength is very compromised,
and then because the postural strength is compromised, bilateral
upper extremity is very compromised as well.

“As you bend in your thoracic spine, you collapse the space
between your scapula and your ribcage. If you collapse that
space, you are inhibiting the ability of the scapula to do upward
rotation. Basically, kyphosis causes an impaired joint that allows
for a lot of impingement to happen. If your muscle below T3-T4
doesn’t work, you’re already pre-dispositioned for a non-optimal
shoulder propulsion.”

Enter the power-assist system, which Merring said he
considers whenever he’s thinking about recommending an
ultralightweight chair, regardless of the potential user’s age or
shoulder history.

Merring said of power-assist, “Can I get this ahead of time
to decrease the demand on the shoulders and also improve the
ability for this person to go longer distances for longer times? It
definitely crosses my mind for each evaluation.

“A lot of the [younger SCI patients] that I see [in clinic] are college
students. They have to be able to get from one class to another
relatively quickly. They’re trying to manage phone calls, they’re
propelling, they’re carrying backpacks. Any sort of device that saves
the physical demands and exertion, and allows them to be more
functional, should be brought to the table during the evaluation.

“As the technology continues to get better and smaller and
hopefully cheaper — reimbursement also sometimes comes
down to the costs of things — hopefully, power-assist becomes
more reimbursable. And as the evidence shows that someone
who pushes 2,000 to 3,000 times a day can, without a doubt,
be assisted in maintaining their shoulder integrity and postural
integrity and be more functional and give back into society, we
should start to see more chairs [using] it.”

What Is the Better Option?

Manual and power mobility have their strengths and weaknesses.
Ultralight chairs undoubtedly have an easier time fitting into
smaller everyday spaces indoors and into cars; power chairs
conserve a consumer’s energy and offer powered positioning and
pressure relief.

“Every decision starts with that person and what their MRADL
needs are specifically,” Merring said. “That’s what’s going to drive
your decisions, ultimately. What do you need to do the majority
of the time?”

Merring acknowledged that choosing a power chair can make
transportation plans more complicated, and he said that as a
rehab director, he made sure to provide new power chair users
with resources, such as community transportation options. “The
worst-case scenario is we give them a power chair for home, and,
because that’s all their funding will cover, they buy a hospital
chair to go to doctor’s appointments,” he said. “That’s the worst case
scenario.”

But despite those potential inconveniences, he said he would
recommend power mobility if it was the better choice overall.

“If [using a manual chair] is really compromising function
and compromising health, and the medical necessity is there for
power, I’d much rather be the advocate for power so the mobility
isn’t sacrificed, and function isn’t sacrificed, and pressure relief
isn’t sacrificed,” he said.

Because deciding between manual and power mobility is such
a critical decision, Merring said he encourages the seating and
mobility team to take the time needed to gather all the information
they can.

“When I do my evaluations, I do a 90-minute evaluation the
first time, and I try not to put any pressure on myself or the
patient or the ATP to make all our decisions that day,” he said.
“We’ll bring [the client] in, we’ll do the initial evaluation. If
it takes 90 minutes just to discuss what the problems are and
what the current chair is, and we only do a measurement, that’s
perfectly fine with me. And then I bring them in for a second and
third visit and start getting some of that other information.

“Don’t feel like you have to do this in one day. Ask the tough
questions. Have a conversation with the person. And know that
there’s no one specific formula for [finding the right answer], just
trial and error.”