August 2016 • Vol. 15 No. 8 Serving the Seating &...

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August 2016 • Vol. 15 No. 8 Serving the Seating & Wheeled Mobility Professional

0816mm_Cover1.indd 1 7/7/16 2:10 PM

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4 mobilitymgmt.comaugust 2016 | mobilitymanagement

contents

8 Pediatric Mobility Pictorial It’s all about the kids: Take a look at the latest pediatric-focused

seating, positioning and mobility technology. PLUS: Making the

case for kids being able to stand, 24-hour posture support, and

Etac emerges as a go-to pediatric player.

Cover Story 21 Comprehending Cushion Codes

Skin protection, positioning, adjustability: How wheelchair seat

cushion codes are defined, and what their definitions do — and

don’t — mean for medical justification.

Mobility Management (ISSN 1558-6731) is published monthly by 1105 Media, Inc., 9201 Oakdale Avenue, Ste. 101, Chatsworth, CA 91311. Periodicals postage paid at Chatsworth, CA 91311-9998, and at additional mailing offices. Complimentary subscriptions are sent to quali-fying subscribers. Annual subscription rates payable in U.S. funds for non-qualified subscribers are: U.S. $119.00, International $189.00. Subscription inquiries, back issue requests, and address changes: Mail to: Mobility Management, P.O. Box 2166, Skokie, IL 60076-7866, email [email protected] or call (847) 763-9688. POSTMASTER: Send address changes to Mobility Management, P.O. Box 2166, Skokie, IL 60076-7866. Canada Publications Mail Agreement No: 40612608. Return Undeliverable Canadian Addresses to Circulation Dept. or XPO Returns: P.O. Box 201, Richmond Hill, ON L4B 4R5, Canada.

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augustvolume 15 • number 8

06 Editor’s Note

26 Clinically Speaking: 20 Years in Bed, Part 2

27 Clinically Speaking: Open CRT & ALS

29 Marketplace: Manual Wheelchairs

30 Ad Index

On the CoverWhat do wheelchair seat cushion codes actually mean? Cover by Dudley Wakamatsu.

mobilitymgmt.com

August 2016 • Vol. 15 No. 8 Serving the Seating & Wheeled Mobility Professional

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mailto:[email protected]

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Editor Laurie Watanabe (949) 265-1573

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mobilitymgmt.com

Volume 15, No. 8

August 2016

REACHING THE STAFF

Staff may be reached via e-mail, telephone, fax, or mail. A list of editors and contact information is also available online at mobilitymgmt.com.

E-mail: To e-mail any member of the staff, please use the following form: [email protected]

Dallas Office (weekdays 8 a.m. - 5 p.m. CT) Telephone 972-687-6700; Fax 866-779-9095 14901 Quorum Drive, Suite 425, Dallas, TX 75254

Corporate Office (weekdays, 8:30 a.m.-5:30 p.m. PT) Telephone 818-814-5200; Fax 818-734-1522 9201 Oakdale Avenue, Suite 101, Chatsworth, CA 91311

Chief Executive Officer Rajeev Kapur

Chief Operating Officer Henry Allain

Chief Financial Officer Michael Rafter

Chief Technology Officer Erik A. Lindgren

Executive Vice President Michael J. Valenti

Executive Chairman Jeffrey S. Klein

SECURITY, SAFETY & HEALTH GROUP

President & Group Publisher Kevin O’Grady

Group Publisher Karen Cavallo

Group Circulation Director Margaret Perry

Group Marketing Director Susan May

Group Social Media Editor Matt Holden

editor’s note

Stop, ThievesTwitter posting is part of my job now, which means every day, I’m scouring the Internet and news wires for stories about wheelchairs, accessibility, mobility-related condi-tions, advocacy and policy, etc.

So every day, I get barraged by news reports of stolen wheelchairs. Multiple wheelchairs gone, taken from different people in different places under

similar circumstances. Chairs are stolen from unattended cars, or some-times the chair is stolen because it’s inside a car that is being stolen. Other chairs are stolen from the porches or yards of homes. Many times, the stolen chairs belong to children. I’m not sure if that’s because stealing a wheelchair from a child is considered more buzz worthy from a “What is this world coming to?” news wire perspective, or if kids’ chairs

are generally easier to steal because they’re smaller and because children spend more time out of their chairs than adults do, thereby providing more opportunity for the chairs to be snatched.

But here’s what I do know: I’m sick of reading about chairs being stolen. Here’s why:• You know it’s a wheelchair. Some chairs are collateral damage from grand theft

auto, but many thieves grab chairs from front steps of homes. There’s no way you’re mistaking that piece of medical equipment for a string of diamonds, a big-screen TV or an iPad. Yes, all theft is bad. But stealing a person’s legs is on a whole different level.

• You know it’s a complex wheelchair. I’m not talking about standard manual wheel-chairs being stolen. I’m talking about customized wheelchairs with accessories from specialized electronics to hard-core positioning components. I accept that thieves prob-ably don’t know kyphosis from lordosis. But you can’t tell me they don’t know that what they’re stealing is very different from the generic wheelchairs they’ve seen in hospitals.

• You know it’s a child’s chair. Again, you’re not stealing a chair that someone first snagged from an airport. That seat is 10" wide, and the larger wheels in back are still only the size of dinner plates. There’s a push handle in the back at Mom-and-Dad height, and the chair is covered in Princess Elsa or Iron Man stickers. You’re stealing the mobility of someone who still believes in Santa Claus and the Tooth Fairy. These robbery reports are accompanied by family members begging for the chair to

be returned: He can’t go to school without it. Now she can’t go outside with her friends. The latest story that made my head spin was about a Utah family whose 1999 Honda Civic was stolen; a wheelchair belonging to their 5-year-old son, who has cerebral palsy, was inside.

You can keep the car, the father said. Just return my boy’s wheelchair. A good Samaritan found the wheelchair abandoned nearby, apparently shoved out of

the stolen car by a thief who would like us to think he or she had a conscience. Except that the seat and back of the wheelchair were missing. The dad then had to explain how the wheelchair was custom fit to his son and is useless without the seat and back.

So, here’s what I wish I could tell wheelchair thieves: You won’t be able to sell that complex rehab wheelchair. It’s one of a kind, useless to anyone but the unique person for whom it was built. To that person, and to his/her family, that chair is rolling to the bath-room like a big boy, without needing Daddy to carry you. It is going to the park without having to sit in the baby stroller. It is catching a softball game on a summer evening and watching sunsets and munching popcorn at a summer blockbuster and eating too much at a block party. It’s a large part of the stuff that makes life worth living.

Give it back. l

Laurie Watanabe, [email protected]

@CRTeditor

0816mm_EdNote6.indd 6 7/7/16 12:18 PM



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ATP Series Let’sRock!

Setting kids into motion — so they chase the dog, fight with siblings, grab things they shouldn’t — is the

ultimate goal of early-intervention mobility. Keeping kids in motion — playing sports, rolling with friends,

participating in school performances — is the goal as they grow. This special pediatric section reaches toward those goals in a number of ways, from showing off seating & mobility that supports and facilitates

function, to getting specific with case studies and the clinical philosophy of 24-hour postural management. — Ed.

Little Wave FlipDesigned to make that first step toward early-intervention mobility more natural for both parents and child, the Little Wave Flip combines popular stroller design elements with the durability and functionality of a wheelchair. This chair offers tilt-in-space posi-tioning in a system that’s easy to grow; the tube-in-tube seat rail design is modular so changes can be made without replacing parts. Seat widths from 10" to 18"; seat depths from 12" to 20".

Ki Mobility(800) 981-1540kimobility.com

Custom SeatingSeating that doesn’t match its user’s specific needs becomes more limiting than functional. Stealth Products creates custom linear seating using the highest-quality materials and pays close attention to detail to create the correct combi-nation of base, foam and cover that meets the client’s current needs and also grows as needed. Standard and customized back packages, plus back inserts, are available.

Stealth Products(800) 965-9229stealthproducts.com

0816mm_PediatricPictorial820v3.indd 8 7/7/16 5:35 PM

©2016 Invacare Corporation. All rights reserved. Trademarks are identified by the symbols ™ and ®. All trademarks are owned by or licensed to Invacare Corporation unless otherwise noted. Form No. 16-152 160675

The first choice for a user’s first wheelchair.

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ATP Series

Pediatrics Pictorial

Folding Zippie IRISThe Zippie Intelligent Rotation In Space (IRIS) wheelchair now comes with a folding option for a new dimension of compact, easy porta-bility thanks to an XLOCK folding crossbrace. Zippie IRIS offers 40° or 55° rotation ranges, plus a rocker arm design that results in smooth, easy-to-control tilting within a compact wheelbase. A foot-release tilt actuator provides hands-free tilting without exposed cables. The angle-adjustable stroller handle fits parents of different heights.

Sunrise Medical(800) 333-4000sunrisemedical.com

558 ATOM Wireless Mouse EmulatorThis wireless mouse emulator, created to pair with the ASL 104 ATOM Electronic Head Array, plugs directly into the USB port on a communication device or computer. Full mouse emula-tion can be achieved with just three switch inputs: Right moves the mouse cursor right/left on the screen. Forward moves the mouse up/down. Left controls left click, double click and drag. The wireless connection works directly with the 104 ATOM Electronic Head Array when it’s in the user switch mode.

Adaptive Switch Laboratories (ASL)(800) 626-8698asl-inc.com

Hygiene & Toileting System (HTS)Proper positioning can be crucial to successful toileting, for child and parents, and Rifton’s HTS strives to provide that optimal positioning. In addition, the open seat facilitates proper cleaning, and an adjustable headrest makes showering easier. The entire system is designed to be easy to keep clean, and it can be used on, over or off a standard or elongated toilet. Adjusts as the child grows.

Rifton(800) 571-8198rifton.com

Bantam XS/SmallEasyStand’s popular Bantam stander, with its famous combination sit-to-stand with supine positioning, is now available in extra-small and small sizes to fit your littlest clients measuring approximately 36" to 54" tall. Bantam offers infinite positioning between 90-90 seating, vertical standing with full extension, and supine/flat to load. A new supine/positioning controller makes changing positions even faster. New, smaller trays, including a swingaway shadow tray, are also now available.

EasyStand(800) 342-8968easystand.com

JUNIOR Cushions & Back SupportsKids are not just miniature adults, which is why VARILITE used anthropometric data to create its JUNIOR line of seat cushions and back supports for active users. Seat cushions are available in a 10x10" size using Air-Foam Floatation. Back supports come in Mid or Deep configurations in a 10" size that fits chairs measuring 9" to 11". Backs use Air-Foam Floatation with pediatric-specific VariLock hardware.

VARILITE(800) 827-4548varilite.com

R82 StingrayAdjustments, comfort and lightness in steering are key attributes of the Stingray wheelchair, which boasts a 180° turnable seat, even with the child seated. Angle adjustability makes it easy to find exactly the position that’s best for any user. With an efficient suspension and a safe and secure braking system, the R82 Stingray is easy to drive for parents while offering functional positioning for the child.

Etac/Convaid(844) US-MOBILITYconvaid.comr82.com


Toll Free Tel: 1.888.433.6818 u Toll Free Fax: 1.888.433.6834 u www.motionconcepts.com

Mobility Management _August Issue 2016_Layout 1 6/29/16 2:07 PM Page 1

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By Lee Ann Hoffman, OT, MSc Rehabilitation: Posture Managementpediatrics clinically speaking

24-Hour Posture Management: An IntroductionThe 24-hour posture management approach considers all the relevant postures an individual has the ability to adopt over the 24-hour period of any given day. The three core postural orientations are lying, sitting and standing.

Consider for a moment that we are healthy individuals able to adopt these three core postures, freely moving in and out of them.

Now consider the reduced ability of an individual who has complex rehab needs. At times, many are functionally compromised, and their functional ability has been significantly reduced. Perhaps they are limited to only standing in a stander/standing frame for one hour a day. This effectively means that the remaining 23 hours are spent either lying or sitting.

Some of our complex rehab individuals may be in a seated orientation for any length of time ranging from a couple of hours right through to 16 hours a day, depending on their situation. I would like to invite you to consider the wide range and variety of seating systems available to address the seating & positioning needs of our complex rehab group.

There are so many, right?The point is that great care and effort is taken to provide the

correct seating system to meet the postural needs of the indi-vidual. Good supportive seating provides an individual with a stable posture in sitting, creating a good foundation for function and serves to promote active participation in daily living.

Excellent! At this point the individual’s standing and seated postures have been supported, and have been provided to meet the individual’s postural needs.

Two supportive postural orientations. Check.In addition for good measure, I am going to add occupational

and physical therapy sessions into the mix. All efforts are aimed towards addressing the postural management needs of the individual.

Unfortunately, this is also the point where most posture management intervention ends.

When Support Is AbsentBut what happens to the body in unsupported postures in the lying orientation? What about the effects of gravity?

Reflect on this fact for a moment: There are 8,760 hours in a year, of which roughly 3,600 of those hours are spent in bed (Goldsmiths 2000).

Gravity will negatively influence the position of the unsup-ported body.

How, you ask?

The sternocostal bridge is a vulnerable site. The chest itself is particularly susceptible to distortion as a result of the forces of gravity in unsupported lying (Goldsmiths 2000, Poutney et al 2002, Pope 2007, Porter et al 2008, Rodby-Bousquet et al 2013). Rotation of the chest will occur in unsupported lying. Chest distortion can have devastating implications, including a reduc-tion in the internal capacity of the thorax and abdomen. This in turn affects digestive and cardio-respiratory function, which can lead to pain, suffering and premature death.

Also, hips are always a hot topic. A study undertaken in 2000 — The Mansfield Project:

Postural care at night within a community setting (Goldsmiths) — provides evidence of effective hip management intervention through the implementation of a 24-hour postural management program. Basically, to promote hip health during the stages of early development, hips are encouraged to be placed into some degree of flexion and abducted (Goldsmiths, McLean et al, Poutney, Pope). Interestingly, the head of the femur is most secure in the acetabulum in the supine lying position (Goldsmiths).

Where to begin?

How Asymmetry BeginsLet’s go back to the start. Healthy babies are usually born with a symmetrical body shape (e.g., no curvature of the spine). However, children with reduced mobility, who are born with or acquire a disability, are significantly more predisposed to asymmetries as their bodies alter and deform, due to the effects of gravity, and influences such as muscle tone (Goldsmiths 2000).

These asymmetrical lying postures become further established through a habitual sleeping position. The net effect is that these destructive, asymmetrical postures may become obligatory as they age, and as their bodies change shape.

A downward spiral is created as postural asymmetries occur, creating further challenges to the individual trying to move into an alternative lying posture. Postural asymmetries increase the risk of tissue adaptation, and are associated with scoliosis, hip dislocations, hip-knee contractures, and an inability to change position (Rodby-Bousquet et al 2013). These postures become known as “preferred postures.”

Preferred lying postures have an impact on the direction of the deformity — hip dislocation, windsweeping, spinal curve — (Porter et al 2008). Therefore, early intervention needs to focus on maintaining symmetry, and assisting those who are unable to change their posture.

The introduction and implementation of safe and gentle positioning in the lying posture may serve to protect against the development of these asymmetries by protecting body shape.

Next month, we’ll look into the biggest challenges in imple-menting 24-hour postural management. l


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ATP Series


REACHFamilies can enjoy time outside and in their commu-nities thanks to the Leggero REACH stroller. An innovative frame design enables tilt to be fixed at 10°, 20° and 30°, and hip angle can also be adjusted. LT seating provides contoured and configurable support to match the child’s needs, and the range of sizes (12", 14", 16" hip width sizes) ensures the proper fit for smaller and bigger kids.

Leggero LLC(844) 503-5437leggero.us

Tarta BackrestsThis ergonomic backrest uses state-of-the-art materials and design concepts to provide adaptable support that optimizes function for busy users, including busy children who experience a range of environments and activities every day.

Stealth Products(800) 965-9229stealthproducts.com

ThevoSleepingStar AThe original ThevoSleepingStar support surface has wing suspensions to provide tiny movement impulses that calm children as they are in bed. The “active” A model additionally provides sensory support by providing the movement for children who cannot supply movement themselves. Choose Wave, Rotation, Inclined Plane or Static from the movement “menu” to reduce pressure, pain and spasms and improve quality of sleep. The quiet system ensures operation without disturbing the child’s rest.

Thomashilfen North America(866) 870-2122thomashilfen.us

Q6 Edge 2.0 iLevelNow kids can be at eye level with their peers, thanks to the Q6 Edge 2.0 power base and pediatric iLevel technology that provides complex rehab seating and power mobility. The system can include tilt, recline and a power articulating foot platform, plus iLevel seat elevation of up to 10" of lift while driving at up to 3.5 mph to keep up with pals. In 12x12" seat sizes and up.

Quantum Rehab(866) 800-2002quantumrehab.com

BORIS Shower Commode ChairThis new, stylish and comfortable BORIS shower chair is available in five sizes and a range of seat widths to fit and support kids from birth into their teens. A UV-protected, PE plastic-molded seat shell gives strong upper-body support, while the stainless steel chassis can be set into a tilted position to provide rest. Gas cylinders smoothly tilt on demand, and the frame height adjusts easily to whatever toilet height is optimal. Positioning accessories include head support, cushioned seat insert, a safety bar/tray, footplates and a splash guard that also performs as an abductor.

Clarke Health Care Products(888) 347-4537clarkehealthcare.com

Otter Bath ChairLightweight and capable of multiple positions, the Otter provides comfort and stability in a bathing chair that fits all standard tubs. It’s available in three sizes and made of a plastic frame that’s covered in standard or soft fabric that is removable and washable. The Otter system includes an adjustable head stabilizer, two positioning straps and leg straps. The seat and back are angle adjustable, with five positioning options. Folds flat when not in use.

Drive DeVilbiss Healthcare(877) 224-0946drivemedical.com


http://www.leggero.us


ATP Series: Case Studies

Making the Case for Standing

On His Feet AgainNow you can use a stander for a person with knee flexion contractures, while preserving hip range of motion. The new knee

contracture brackets from Prime Engineering can be added to any SuperStand Stander. Traditional sit-to-stand devices link the amount of hip and knee flexion so that you cannot bend one joint without bending the other. This new system allows for full adjustments on all planes and can accommodate severe asymmetries.

My case comes from Los Angeles and involves Vicente Capati, PT, California Children’s

Services, and Karen Hobson, PT, Richard’s Rehab Solutions. They were challenged to accommodate a 17-year-old boy with spastic tetraplegic cerebral palsy, level V on the Gross Motor Function Classification System (GMFCS), Manual Ability Classification

By Ginny Paleg, PT, DScPT

Stronger & StrongerThrombocytopenia-absent radius syndrome (TAR), of which there are two types, short arm and long arm, is an extremely

rare condition impacting fewer than one in 100,000 newborns. Affected individuals have a defi-ciency of blood cells involved in clotting (platelets) and can require hundreds of blood transfusions every year. Children who survive infancy and do not have damaging hemorrhages in the brain usually have a normal life expectancy and normal intellectual development.

Mutations in the RBM8A gene cause TAR syndrome. The

RBM8A gene provides instructions for making a protein called RNA-binding motif protein 8A. This protein is believed to be involved in several important cellular functions related to production of other proteins.

Some children with TAR also have malformations of the heart and kidneys — Kade, who came to the attention of Wendy Altizer, PT, ATP, doesn’t have those difficulties. But about half of children with TAR have allergic reactions to cow’s milk that may worsen the thrombocytopenia — and Kade does have that. He also needs the very frequent blood transfusions associated with TAR.

Kade was hospitalized for one week after birth and sent home after three transfusions. He has had multiple Broviac ports placed in his left pectoral region to ease transfusions. He was referred into an education-based early-intervention system in April 2015, and his outpatient referral for medical-based therapy began in May 2015.

At Kade’s initial assessment Wendy noted minimal hand movement, externally rotated lower extremities, and knee flexion contractures of 120° bilaterally, although Kade had the ability to achieve a neutral heel/foot position. Kade was very alert and visually attentive. He presented with right head tilt and left rotation, but no range limits. He was able to kick his legs using hip flexion movement.

Wendy uses lots of gait trainers, and Grillo and KidWalk are her favorites. She prefers the prone position of the Grillo and arm supports for her older children and those who need to lean forward. For more upright gait, she uses the KidWalk and appreciates the dynamic movement in all their planes of motion.

System (MACS V), Communication Function Classification System (CFCS V), and Eating and Drinking Ability Classification System (EDACS IV).

He presented with bilateral knee flexion contractures (35° right, 30° left) and hip flexion contractures of 20° right and 30° left. When he was in kindergarten, he enjoyed being fed and watching TV while standing, and the family wanted to try to return to this.

The team quickly realized that a traditional standing frame would not accommodate his deformi-ties. The knee flexion contracture brackets from Prime Engineering were large and padded, adjustable at both ends (tibia/femur) and allowed this teenager to stand. He was so happy and his family is able to use the stander regularly at home. l


mobilitymgmt.com 17 mobilitymanagement | august 2016

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Recently, Wendy saw children with inseams of 6" and less. The KidWalk was just too high for them. She contacted Prime Engineering, and they told her about their extra-small early-

intervention model. Now she has all the features she loves for her itty-bitty clients!

Kade’s therapy team at Milestones in Hurricane, W.V., used Hip Helpers to de-rotate his hips and start work on rolling, which he accomplished inde-pendently at 7 months. The team addressed range of motion, trunk strength and vestibular function, and used lots of strategies and equipment to encourage play and

exploration, including a Bumbo chair, Jenx Giraffe chair, aquatics to initiate movement, Oball toys, switch toys, a self feeder, a SuperStand HLT EI and a KidWalk EI. Wendy choose the KidWalk Ei because of its ability to go very low, and she modified the soft trunk support to allow Kade’s hands to be free.

Kade loves walking, and it’s making him stronger and improving his endurance! l

TWISTThis growable, rigid ultralight-weight chair encourages exploration while providing a safe environ-ment to learn new skills. The TWIST offers 2" of seat width growth plus 3" of seat depth growth, and requires no parts or growth kits. A 1" aluminum frame design makes for easy installation of seating components. A center-mounted push handle option allows Mom and Dad to lend a hand when needed. TWIST has a 165-lb. weight capacity.

TiLite(800) 545-2266tilite.com



http://www.thomashilfen.us


Pride Mobility Products® granted patent directed to performance andsafety features included in the iLevel® elevating power chair.

INDUSTRY NOTICE:

Pride Mobility Products® has been granted U.S. Patent No. 9,351,889 directed to performance and safety features included in the iLevel® elevating power chair. Pride Mobility Products’ elevated power chairs such as iLevel and Jazzy AirTM incorporate features that selectively limit suspension travel when the power chair seat is in an elevated position to enhance stability of the power chair.

Patent No.US 9,351,889 B2

33 Claims

Scan to viewfull patent.

Chris Braun: Etac Aims to Be Pediatrics’ “Go-to” SourceAfter a major acquisition, it’s fairly common for both entities — the acquirer and the acquired — to keep low profiles as the

transition takes place.But that’s hardly been the case

with Etac AB and Convaid.Etac announced in December

that it had acquired Convaid, a fellow manufacturer of pediatric mobility equipment. But after that, the announcements kept coming. In March, Convaid President Chris Braun was named president of Etac North America. In May, Braun announced that Convaid’s and Etac’s sales and marketing forces

would be integrated.On top of all that, Convaid launched two major products in

the first half of 2016: the Carrot booster system, which makes

the well-received car seat accessible to bigger kids, and the YoYo hi-lo activity base. The YoYo base uses the seating from Convaid’s Trekker, the stroller-style chair with robust positioning functionality.

A Range of Pediatric SpecialtiesIn an interview with Mobility Management, Braun said these product launches were good indications of what the industry can expect from Etac — including its pre-existing pediatric R82 line.

Of the acquisition and accompanying transition, Braun said, “This allows us to position the new entity, if you will, as the premium pediatric supplier. Our goal is to essentially take the same approach we had, which is creating the best in class products, but take it into all these new categories. So if I look at it from a customer perspective — the kind of product and quality and innovation that they knew from R82 and they knew from Convaid now is just on a completely different level.”

Adding Convaid products to the Etac family gives the company

pediatric news

Chris Braun



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coverage in a wide range of pediatric categories: seating & posi-tioning; standing/gait; mobility; transportation, including car seats; bathing/toileting/hygiene; and patient transfer.

“Those are the major categories of focus, and I think that’s a different spot from what R82 individually had in the market,” Braun said. “Many R82 customers today would say, ‘I use you all the time for gait trainers’ or ‘I use you all the time for bathing and toileting products’ or ‘I use you all the time for the Caribou.’ But what I didn’t hear a lot of was ‘You have a full line of product offerings for pediatrics.’”

Braun expects that to change — and Convaid has already sent that message with its two product launches this year. Neither the Carrot booster car seat nor the YoYo activity base is in Convaid’s previous “core” market of manual mobility. But Etac’s greater message is that clinicians and ATPs can now look to the company to support children, teens and their families throughout the day, in different environments, and through different activities.

Braun said Convaid and R82 are also positioned to support children with mobility needs ranging from less involved to severely involved.

“Let’s say they’re on the autism spectrum — you don’t need transfer products and some of the more complex things that would be needed for kids with spina bifida,” he explained. “We’re

talking about [supplying] a few very specific products that work in the lighter disability range, and as you go through the different levels of disability, [clients] would have more product groups to meet their own requirements. With autism spectrum and Down syndrome, I think those are perfect one or two category users. And then all the way to spina bifida, spinal muscular atrophy, extreme cerebral palsy — those children are going to use products in five or six of categories.”

Interestingly, as Convaid was delving deeper into products that accommodated children with more severe needs — the Trekker’s positioning functionality being proof of that — R82 was expanding to include products for children on the less-involved end of the spectrum. The result is Etac’s expanded ability to meet special needs children and families wherever they are.

“You have basic bathing chairs, like the Manatee,” Braun said. “But you also have the Flamingo. We’re trying to fill out within those categories, to meet needs all along the spectrum.”

Appearance MattersAesthetics is crucial in complex rehab products, and a wheelchair or gait trainer’s appearance can go a long way toward deter-mining how it’s accepted by the child and his or her family.

Appearance is a trait important to Etac as a whole, Braun said.


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pediatric news

Etac: “Go-to Source” for Peds“Both companies on their own were in that position in the

marketplace that if you asked somebody, ‘What do you think about this product?’, people would use the same types of adjec-tives to describe it,” Braun said. “The quality was there, the inno-vation was there, certainly the convenience. They were aestheti-cally nice-looking products, but they were also easy to use.”

He added that North American design and engineering teams are working closely with their counterparts in Denmark — where Etac is based — so that a product “does all the things that the therapist wants, yet it makes families happy to have that product as part of what they’re using with their child every day.”

Expect to see more from the Molift line as well, as its lifts are capable of helping with both pediatric and adult clients. Braun believes the patient transfer market is under-utilized among families with special needs children, and that compact, easy-to-use lifts can be a huge help, particularly as kids become teens.

“These products work extremely well for those children, and I think there’s a big spot in the market that will very much enjoy this product and get a lot of utility out of it and still not have it be an eyesore in houses, schools and clinics,” Braun said. “It’s lift, transfer and safety, and there is a very good part of the market that we can help within the pediatric space.”

Braun pledged that despite their international lineage, all future products would retain a “local focus” to ensure they were optimally configured and appropriate for their varying markets.

He declined to offer too many details about what’s coming next, but also wouldn’t rule out launches in any of the major pedi-atric seating & mobility categories.

“We have an extremely full pipeline of products coming down,” he said. “It’s super fun stuff that I think will do well in the marketplace. We’ve had extremely good initial feedback from a few different clinicians and families who’ve tried some products. Our goal is really to be the go-to pediatric company.” l

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Funding Series

By Laurie Watanabe

Skin Protection, Positioning & Adjustability: Their Impact on Funding

Cushion Codes DefinedE2603: Skin protection cushion, width less than 22",

any depth.E2604: Skin protection cushion, width 22" or greater,

any depth.E2605: Positioning cushion, width less than 22", any

depth.E2606: Positioning cushion, width 22" or greater, any

depth.E2607: Skin protection & positioning cushion, width

less than 22", any depth.

E2608: Skin protection & positioning cushion, width 22" or greater, any depth.

E2622: Skin protection cushion, adjustable, width less than 22", any depth.

E2623: Skin protection cushion, adjustable, width 22" or greater, any depth.

E2624: Skin protection & positioning cushion, adjust-able, width less than 22", any depth.

E2625: Skin protection & positioning cushion, adjust-able, width 22" or greater, any depth.

The definitions for the wheelchair seat cushion codes mentioned in this story:

Source: HIPAASpace.com

SSo much depends upon wheelchair seat cushions, particularly for clients with complex seating needs. An optimal cushion in the right seating system can give its user more comfort, safety and function in his or her wheelchair. The wrong cushion can be catastrophic.

So much therefore depends upon cushion funding, which in turn depends on a cushion’s HCPCS code. The variables for cushions commonly used by complex rehab clients are skin protection and positioning — used alone or together — plus adjustability. And it’s much more complicated than it sounds.

Cushion History, RevisitedTo understand current cushion codes, it’s helpful to look at their history — how codes were written and why.

That means going back more than 10 years, when industry experts worked with Doran Edwards, M.D., medical director of Medicare’s Statistical Analysis DME Regional Carrier (SADMERC, which later became the Pricing, Data Analysis & Coding contractor [PDAC] after a contractor change), to revise cushion codes.

Rita Stanley, Sunrise Medical’s VP of government relations, was among the industry members working on the project.

“Part of what Dr. Edwards was doing was looking at the different technologies and trying to understand the different materials that are used,” Stanley said. “‘Is there a difference between foam and fluid, and do I

0816mm_CushionCodes2125.indd 21 7/7/16 6:33 PM


Funding Series

Comprehending Cushion Codescare? When do I care, and how do I know when enough is enough?’ [Edwards] reached out to RESNA; he talked to the committee involved in developing those tests and getting those tests passed, approved and accepted as an ANSI/RESNA test, and part of the issue that we ran into in 2004 is there wasn’t enough time. It’s not an easy thing to do, creating a new test and getting it signed off by all the different people who serve on those committees and boards. He ran out of time to have RESNA create a new test that would test this concept of adjustability.”

When the new codes first came out, Stanley said, “There

was just skin protection, positioning, and the combination of skin protection and positioning.” The result: Different forms of technology with varying efficacies were in the same code and therefore received the same reimbursement.

“Products that were fluid based, air-flow based — JAY prod-ucts, ROHO and others — were suddenly not available because the reimbursement level for a basic skin protection cushion just wouldn’t have allowed it,” Stanley said. “The response of the stakeholders, whether consumers or clinicians or manufacturers or suppliers, was pretty extreme and immediate. So I think

CMS (the Centers for Medicare & Medicaid Services) and Dr. Edwards realized, ‘We’ve got a problem and we’ve got to address it. But how do we address it? Because we don’t have time for the ANSI/RESNA test component of this.’”

Preserving Code IntegritySkin protection wasn’t the only area that caused concern, says J. David McCausland, VP of planning & government affairs for ROHO Inc. McCausland was also part of the industry team that worked with Edwards.

“When we created the seating policy, we felt it was important that products assigned to codes met certain performance character-istics, that [they] also met certain durability characteristics, and certain safety characteris-tics,” McCausland said.

The seating policy includes an immer-sion test — originally developed by Stephen Sprigle, Ph.D., PT, McCausland noted, and also known as an “indenter” test — plus an aging test to measure a cushion’s longevity and a fire retardancy/safety test. But the tests lacked certain specifics that have proven problematic.

“The indenter test basically pushed these cylinders, which were 40 cm long to represent the ischials, down into the cushion to see if they could immerse so far,” McCausland said. “The way they were to evaluate durability is you would then age the product. Some of the cushions would be aged to a year; in other situations, the cushion was to be aged to 18 months. And then you’d run the immersion test again. The logic was Does it continue to function after 18 months of simulated use? So it’s not five years of durability, but at least you know that the product continues to provide some benefit over some period of time.

“Here’s the problem: They did not put in the

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policy any requirements with regards to what anybody has to do to accelerate aging on their product. There was no description, no minimum requirement, nothing about laundering, nothing about repetitive loading, and nothing about heat aging. It was really subject to interpretation, and you could have manufacturers that perhaps were a bit too lenient in what they considered to be the minimum aging before they’d run the test again.”

McCausland said the safety test also lacks practicality.“We have a fire-retardancy test, but it’s the California

[Technical Bulletin] 117 test, which is basically a cigarette test. Does it really make sense to do a test of an open flame sitting on top of a cushion, when realistically, that’s where the person would be sitting? You need to do fire tests or safety tests looking at the edge or looking at something from the bottom.”

Adjustability: Macro vs. Micro ChangesIn addition to skin protection and/or positioning, current cushion codes include categories for adjustability, a concept that Stanley said has been particularly difficult to capture.

“There had been originally a concept that adjustability had two meanings,” Stanley said. “It was adjustable in that you could put air in it, you could put fluid in it, and then you could take it out or add it at a later date to adjust it. That was one way to look at it, and

that might be important if you had a person that gained weight, lost weight, whatever the situation was that the clinician decided in the field, ‘This isn’t meeting their needs right now.’

“The other piece of it was critically important when it comes to skin protection. And that was Does the material have the capacity to adjust throughout the day as the person moves or shifts or changes how they’re sitting on that cushion? And that is a much more difficult part of the cushion to test.”

Though clinical experts worked to develop a test that could quantify a cushion’s ability to make “micro” adjustments throughout the user’s day, eventually the team ran out of time. The result, Stanley said, was cushion policy that limits adjusta-bility to “macro” adjustments — the ability of a skin protection cushion to be modified after delivery to the client. Left out of the policy: a cushion’s ability to adjust on the fly in response to weight shifts that wheelchair users have when rolling down a ramp or leaning to pick something up from the ground.

McCausland’s issues with the adjustability portion of policy start with the adjustable cushion’s construction.

Examine the local coverage determination, which says, “Wheelchair cushions containing a fluid medium — air, gas, liquid or gel — that have the capability for the immersion charac-teristics of the cushion to be altered by an addition or removal of


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Funding Series

Comprehending Cushion Codessome new coding. But we bastardize the integrity of the codes if in fact we start assigning products that don’t meet the descrip-tion into these codes. I know we worked very hard to make sure we had a definition that met the skin protection needs of these individuals over time. And you can’t do that with a solid piece of foam. It has to have a fluid that you can add or remove.”

How Codes Impact FundingStanley is concerned that the loose definition of adjustable — one that takes macro, but not micro adjustability into account — could hurt funding for cushions that do offer more complete adjustability.

Some 12 years after the industry worked with Edwards, CMS has “lost sight of the need to adjust that definition to also include the adjustable characteristic of the material that the adjustable cushion is made from,” she said. “That’s a really critical thing that’s missing, so when people start saying, ‘How do I decide? Do I need just a skin protection cushion, or do I need an adjustable skin protection cushion?’ — I would suggest that people who are most capable of making that choice do it based on their experience as wheeled mobility and seating specialists or wound care specialists who have observed how their patients respond to different technologies. It’s that evidence-based practice, it’s evidence that has been observed through years of doing it that allows those clinicians to be knowledgeable about the technology and how their particular patient presents. They know they need air or they need fluid or they need this kind of material, and that’s only likely available in an adjustable cushion code.

“It’s their understanding and knowledge and experience as therapists and clinicians that’s going to drive them to the right cushion. It’s not going to be based on policy or the definition of the code as CMS has it today.”

Manufacturers who want both macro and micro adjustability in their cushions — who “are going to genuinely develop inno-vative product that makes every effort to address all the elements that contribute to skin injury,” as Stanley said — will be chal-lenged by other manufacturers who take the less expensive route of concentrating just on cushions with macro adjustability.

And there’s also the potential that CMS will take a closer look at micro-adjustable cushions and wonder whether the extra costs are justified — especially because adjustable cushions are not part of Medicare’s competitive bidding program.

“Standard skin protection cushions have been in every round of competitive bidding,” Stanley pointed out. “So as you see the reimbursement for a standard non-adjustable skin protection cushion go down further and further and you have more of a delta between the adjustable and the non adjustable, that’s going to make payors say, ‘Tell me again why I’m paying that much more for adjustable. What is it?’ And we’re missing the ability to demonstrate some of what’s really critical and what makes the differences between those categories of products so important.”

To explain how two very different seat cushions can have the same HCPCS code, Jeff Rogers, senior JAY seating product manager for Sunrise Medical, compared two current Sunrise Medical cushions.

“In our Fusion, our focus is our fluid technology,” Rogers said. “It has a combination of a hard structural foam for stability and a

high-resilience softer foam for comfort, and it helps with skin protection. Then on the other side in that same code, we have our JAY J3 cushion, where we partnered with ROHO and have the air bladder put in the well. It’s more focused on a prescribed fit with the air bladder. It’s similar materials, but two very different products. They’re both E2622.”

Rogers added that different seating philosophies can lead to different tech-nology approaches.

“We’ve seen competitors in the market focusing on different ways of providing cushions,” he said. “We hear the term ‘off-loading’ a lot, where people are supporting the [client] where they feel fit and not as susceptible to pressure sores.

However, that can feel very uncomfortable. For the Fusion, we focus more on immersion and allowing a uniform pressure across the individual to distribute the weight and bring the pressures down. So two very different ways of tackling a similar problem, but both of them are in the same code.” l

Two Cushions, Same Code

fluid will be considered adjustable. The adjustment may be in the manner of direct addition or removal of the fluid, e.g., adding or removing air, or indirectly by the addition or removal of packets of fluid. … Adjustable as applied here requires that the procedure is capable of being performed by the beneficiary or caregiver using the items supplied at the time of the initial issue of the device in response to the beneficiary’s need for more or less skin protection because of weight loss, gain or muscle tone changes.”

McCausland noted, “So that has several key points in it which I think need to be called out. It calls out that there has to be a fluid medium in it. That the fluid medium is specific for skin protec-tion. That the adjustment has to be capable of being done by the beneficiary or caregiver in response to the beneficiary’s need for changes over time. The whole thought of an adjustable cushion is [the client is] going to change, so we have to make sure the cushion can change to continue to provide them the best envi-ronment. That’s right in the policy, and yet the PDAC over the last few years has started coding products to the adjustable codes that have no fluid, [just] a slab of foam.”

His point, McCausland said, was not to “bad-mouth any of these products. They might be very good, and maybe they deserve

JAY Fusion

JAY J3



McCausland agreed that competitive bidding upended what had been an industry system of checks and balances. “For so many years, we were used to fee-for-service structures,” he said. “Even if you had 2,000 items assigned to a single code, if the dealer wanted to maintain their livelihood, they had to satisfy the caregiver, the clinicians and the end user. There’s nothing worse for a provider than ticking off one of your referral sources. So ultimately, even if there were a variety of products, some questionable, within a code, you still had a clinical gatekeeper that said, ‘No, we want this within the code.’ The provider was risking their livelihood if they did not meet the clinician’s recommended desires.

“Competitive bidding turns that on its head. Now, you’ve got a bidding program where Medicare asks you to bid a code. And the low bid wins. You are taking a lot of the clout out of the hands of the clinicians because the clinician can’t say, ‘Fine, I’ll go to the DME down the street,’ because [that provider] didn’t win.”

Cushion codes are a big topic, one not swiftly or easily solved. But McCausland was still asked: Bottom line, what reforms would he want to see?

“We need to make sure that from the manu-facturers, from the providers, certainly from the governmental contractors that are assigning products to codes, that items do meet the requirements in order to be assigned to a code, and we don’t bastardize codes by allowing products in there that don’t meet the minimum specs that exist today,” he said. “I would tighten up the minimum criteria, I would make sure the contractors were enforcing those criteria, I would take away a manufacturer’s right to self-certify their test results, which is another thing that causes weakness. If I do those three things, I have raised the bar a lot. We would be a long way toward providing beneficiaries with at least some minimal assurance that the products they’re getting are going to address their clinical needs, last for the period of time they need it and not cause them any sort of a danger.”

Stanley was asked the same question.“I would say better defined [codes], more

specific, so you have requirements so all the manufacturers are on the same playing field and what’s being provided for the money is similar, and then it becomes a little easier for clinicians to understand,” she said. “You’ve got codes and you’ve got coverage policy, and it all follows each other then.”

And she would like an industry cushion test to show the differences between macro and micro

adjustability, and how they help the client. That might make CMS more willing to refine those adjustability codes.

“I personally think,” Stanley said, “that it’s real important for us to do that before CMS starts saying, ‘Wait a minute, what’s the difference in these? Because the price differential is meaningful, so how do we know it makes a difference?’ I think we need to be stepping up and addressing that prior to it being a concern.

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By Lee Ann Hoffman, OT, MSc Rehabilitation: Posture Managementclinically speaking

Case Study: 20 Years in Bed, Part 2

References • Aburto N and Holbrook N (2009) Material Choice in Custom Moulded

Seating for People with Neuro-degenerative Disorders. Posture and Mobility Group. Vol 26:1 (17-21). https://www.pmguk.co.uk/compo-nent/option,com.../task, doc_download/

• Hare N 1987 The Human Sandwich Factor. Congress presentation, Chartered Society of Physiotherapy, September, Oxford.

• Pope PM 2007 Severe and Complex Neurological Disability; Management of the physical Condition. Elsevier: Butterworth Heinemann.

• Royal Hospital for Neuro-disability (RHN) http://www.rhn.org.uk/our-work/our-services/assessments/smart/introduction-to-smart/

• World Health Organization (WHO) 2001 International Classification of Functioning, Disability, and Health (ICF) http://www.who.int/classifications/icf/en/ l

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Imagine spending 20 years straight lying in bed, in an unsup-ported position and with no ability to optimally and frequently reposi-tion yourself to maintain range of motion or prevent contractures.

Now imagine being the clinician who gets the call to help such a client become mobile, with the ultimate goal of once again being able to sit up and regain mobility via a wheelchair.

That’s what Lee Ann Hoffman, OT, MSc Rehabilitation: Posture Management, described in part 1 (July issue) of her work with client Alan Tombs, his family and the rest of his seating & mobility team. A gradual, but remarkably efficient postural plan started by moving Alan, who’d sustained a serious brain injury decades ago, into a more symmetrical position in bed. That led to preparing Alan to sit upright: “Careful and graded raising of the head of the bed to simulate a more ‘vertical’ than horizontal plane, with continuous observation for factors such as postural hypotension, was undertaken,” Hoffman noted.

Eventually, Alan was able to sit up via a custom-molded seating system. But the rehab team’s work still wasn’t finished. — Ed.

Positioning for BathingWith the implementation of a graded ‘sitting-out’ plan, great gains were made, lasting up to four hours, three times a week — no pressure areas — thus providing a good foundation to build upon. This increased ability to sit out of bed was accompanied by an increase in endurance and stamina.

The neuro-OT was able to access the sensory room and other therapy areas in the unit to continue with the Sensory Modality Assessment and Rehabilitation Technique (SMART) assessment.

However, one vital area remained unaddressed, namely the shower chair commode (SCC). How many SCC commodes out there could actually accommodate the specific shape required? The simple answer was not one!

Here again, some clever team thinking and creative engineering gave rise to a SCC mobility base (by RAZ Design), with the addition of a Matrix EasyFit custom seat with integrated surface nodules. After a risk assessment-benefit analysis process, the decision to

use Matrix EasyFit was made with the aim of allowing water during showering to actually make contact with the person. This is encapsulated in a term I have now coined as “maximum wettage.”

Having done more than my fair share of “wash and dress” sessions as an OT, my concern was how else is someone going to get wet in the shower if there is no way the water can actually make contact with their skin?

An addition that we added to the shower chair commode was the attachment of a lower-limb mesh hammock (not included in the photos) to provide some degree of support and feedback to Alan’s lower limbs and feet when seated in the SCC.

Begin with the BasicsAlan’s case as described here is ongoing, and his 24-hour posture management program continues with frequent reviews and adjustments as progress is made.

If you ever get a phone call about seating someone who has complex positioning needs, do not decline your valuable assis-tance because you think it is impossible! Remember to revert to the basics of your profession — start with small steps using the building blocks of posture and the creation of a stable posture in lying, and then a stable posture in sitting.

Anything is possible — simply use your knowledge, imagination, creativity and teamwork!

Thanks to Alan Tombs and his sister Julia Brown, Phil Swan and Zeeshan Shafi from Contour 886, Bridget Churchill from Life4Living, Janet Radcliff from Symmetrikit and the QA Unit Rehabilitation staff, United Kingdom. l

“Maximum wettage” was the idea behind a custom shower commode chair.

After 20 years, Alan was again upright and well positioned, with the chance to be more active every day.

0816mm_ClinicallySpeakingHoffman26.indd 26 7/7/16 2:12 PM

https://www.pmguk.co.uk/compo-nent/option



http://www.rhn.org.uk/

http://www.who.int/


Whether you are a clinician, manufacturer or supplier, the future of complex rehab will ultimately depend on our ability to demonstrate that complex rehab technology (CRT) makes a differ-ence. Simply put, it’s about getting successful outcomes.

In my June column, I wrote that successful outcomes require accurate understanding of the person, their problems, products and effective configurations. While each area of expertise tends to be associated with the clinician, manufacturer or supplier, we cannot simply “stay in our lanes” and assume we will get the outcome we want. Effective solutions require us to stay actively engaged, validate our assumptions, and critically analyze the problem from as many perspectives as possible.

Every day, clinicians and suppliers do just that for clients who need CRT. They accrue “practice-based evidence” every time they critically assess how well a given product, provided in a specific configuration, met the needs of its intended user. What most of us don’t do often enough is share that information with others.

Open Complex Rehab applies “open innovation” and “open development” to CRT. It is based on the premise that sharing practice-based evidence is necessary to improve the effectiveness of CRT for specific populations. I’ll demonstrate how Open CRT can benefit users with amyotrophic lateral sclerosis (ALS).

How ALS Challenges CRT ProvisionALS is a progressive neurodegenerative disorder affecting motor neurons in the motor cortex, brainstem and spinal cord. The diagnosis of ALS implies evidence of degeneration in three of four neurological regions (bulbar, cervical, thoracic and lumbosacral). Weakness usually develops in an extremity or in bulbar muscles that control oral motor function, and spreads to other regions. We won’t know for certain what the next region will be, but eventually no region will remain untouched.

Some individuals have “functional variants” of ALS charac-terized by very distinct patterns of weakness. Perhaps the most challenging of these variants for seating/wheeled mobility professionals is “flail arm syndrome.” These individuals will lose function in their upper extremities, but retain fairly good func-tion elsewhere. Approximately 10-15 percent of the veterans I see have this functional variant. Since they are usually unable to use a conventional joystick, they require complex configurations capable of taking advantage of function they have elsewhere.

Regardless of the region of onset or functional variant, there eventually is extensive loss of motor neurons in all regions. In time, most individuals will lose the ability to control the muscles responsible for movement, breathing, swallowing and talking. The result is extensive paralysis. Those who don’t die due to secondary complications will become “locked in.”

We do know that progression of weakness in a given individual will be fairly linear, but the rate of progression among individuals varies significantly. Those who have rapid onset of symptoms tend to progress rapidly; those with more insidious onset tend to live

longer. This creates a significant variation in life expectancy. In the majority of cases, death from respiratory complications will occur in three to five years, but some individuals die within months, while others live 10 years or longer.

ALS poses challenges because we do not know the next symptom or how quickly it will appear. We know we will need at some point to address changes in function, but we will not know what changes we need to make. We know some individuals will use their chairs for years, while others will die before they receive a power chair that needs to be ordered. They may benefit from an existing power chair, but reconfiguring a previously used chair so it effectively meets the needs of a new user can be labor intensive if it was specifically configured to meet the needs of its previous user using our conventional “snowflake” approach.

While we don’t know exactly what is in store for a given user, we can utilize practice-based evidence to identify predictable issues and incorporate solutions into the configuration of an ALS power chair so many of these issues may be addressed before they are even identified as problems.

Solutions that Anticipate Future NeedsMany predictable manifestations of ALS that we can address through a power chair’s configuration are directly related to the influence of gravity. As such, we should account for gravity in every context in which an ALS power chair is likely to be used.

Movements that can appear to be effortless in one plane may become quite difficult in another. Consequently, we need to know about the user’s strength and active range of motion when they are sitting upright and when they are tilted. Eventually, the weight of the affected body part will exceed the muscle’s capacity to overcome the force of gravity in a given plane.

ALS power chairs should be configured to be operated by a user who has 3/5 strength (full range of motion against gravity, but unable to tolerate resistance). The amount of anti-gravity move-ment to operate the chair should be minimized, and we should provide a base of proximal support where antigravity movements take place. Since weakened muscles will be very susceptible to fatigue, the need to sustain efforts should also be minimized. Here’s a “low, level and inline” joystick configuration (right):(a) Joystick inline and roughly level to the surface of the arm pad

with a neutral wrist and forearm. (b) Proximal stability

with even distri-bution of pressure along length of arm pad.

(c) Armrest parallel to seat rail at back angle needed for breathing and stability.

By Steve Mitchell, OTR/L, ATP

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clinically speaking

Open CRT for ALS: A Demonstration

0816mm_ClinicallySpeakingMitchellBest Picks2728.indd 27 7/7/16 3:31 PM


clinically speaking

(d) Elbow stop only makes contact when tilted.(e) Armrest height provides glenohumeral support without

restricting elbow movement.Gravity also has a detrimental effect on posture during upright

sitting. Progressive postural rounding and a forward migration of the head are inevitable. The further the head moves away from the body, the greater the rounding becomes, and the more severe the implications will be for the user’s quality of life.

Here, we need to be more proactive in our approach. Users with ALS should be encouraged to frequently tilt their seating systems in the early stages of the disease to counter the adverse effects of gravity. Tilting may not prevent postural rounding or a forward migration of the head, but it may be the most effective tool we give them to mitigate the rate of progression.

We also need to recognize that as axial weakness causes head and trunk control to deteriorate, these individuals will lose the ability to “sit perfectly.” Excessive posterior pelvic tilt becomes the norm, not the exception, and they will sit slightly differently every time they use their chair.

When they tilt, their entire body will migrate toward the back of the seating system, the position of their head relative to the body will change, and their distance away from the headrest will change by inches. We need to recognize these changes when we position joysticks, provide remote switch access or configure systems for head-controlled driving.

Practice-based evidence can also be used to develop modular assemblies or more specialized configurations and to allow us to address many less frequent, but very challenging issues we can expect to encounter in a subset of users. The ability to easily

implement technology and replicate solutions in the future can recoup the investment of time and effort needed to develop them.

Lastly, there are times when practice-based evidence makes it evident that innovation is necessary to meet unmet needs.

Headrests that provide comfort, headrests that provide posi-tioning, and head arrays are widely consid-ered to be three distinctly different products. Many individuals would benefit from characteristics of all three.

ALS affects function in every part of the body, yet today’s alter-native driving system configurations are designed to be operated using just one body part. Versatile systems that take advantage of function wherever it exists are needed.

Why haven’t manufacturers developed products to address these unmet needs? Maybe we haven’t shared practice-based evidence to identify these needs and propose innovative solutions. I’ll have specific examples in my next column. l

Editor’s Note: Steve Mitchell works at the Cleveland VA Medical Center. His opinions do not represent official policy or positions of the Department of Veterans Affairs.

Open CRT for ALS: A Demonstration


F3 Power Wheelchair BaseIt just works!

— Jeff Cupps, ATP, NumotionPermobil(800) 736-0925permobil.com

Focus CRSecure and smart tilt: These features make uncontrolled tilting no longer an issue. I used to hang onto wheelchair push handles to make sure that when tilt was activated, the seated individual would not be “dropped” or jolted into tilt. Very scary when that happens!

Ki Mobility(715) 254-0991kimobility.com l

IIn our July issue, we listed our 2016 Best Picks winners, as chosen exclusively by the industry’s ATPs and clinicians. In the editing process, we inadvertently omitted two Best Picks from the July layout. We’re printing them here, with our sincerest apologies to the winners and the complex rehab professionals who chose them. — Ed.

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manual wheelchair marketplace

ADI Disc BrakesThis first fully integrated braking system gives users the ability to fully lock the wheels and engage in effortless, controlled braking, even while descending ramps. Brakes can be locked with fingertip effort; a variable lever provides brake operation for users with limited trunk control and function. A paralever is available for active users with more trunk control and function. An atten-dant lever is also available.

Accessible Designs Inc. (ADI)/Stealth Products(800) 965-9229stealthproducts.com

SmartDrive MX2The MX2 second-generation power-assist system can enable manual wheelchair users to power up steep hills or ramps and power through thick carpet, thus preserving their energy and effort. The intuitive MX2 requires just a push to go and a tap, then a brake to stop. The lightweight system works for miles on a single charge. It can be added to the wheelchair when it’s needed, and easily disengaged and removed when not in use.

Max Mobility(800) 637-2980max-mobility.com

TrekkerLightweight, compact and fold-able, the Trekker is fully custom-izable and supports functional or resting positions via its tilt-in-space feature. The chair offers up to 170° of adjustable recline and tilt from -5° to 45°. With a separate base and seating module (seating is reversible on the base so a child can face outward or toward care-giver), Trekker can serve multiple purposes and offers the ultimate in versatility. It’s available in a wide range of attractive colors.

Convaid(310) 618-0111convaid.com

APEXCutting-edge carbon fiber technology gives the ultra-lightweight design of the new APEX outstanding strength and durability. With a transport weight of just 9.2 lbs., APEX provides superior weight in a fully adjustable rigid chair. A more open, responsive design concept increases rear-frame rigidity and improves lateral stability, while maintaining top-of-the-line comfort and easy transportability for active lifestyles.

Motion Composites(450) 588-6555motioncomposites.com

Top End Crossfire T7AWelded caster head tubes elimi-nate the need for an adjustment in a high-impact area of the Top End Crossfire T7A, thereby preserving performance for the long haul. This specially designed high-performance frame endures the rigors of everyday use and provides a smooth, efficient ride for active users who need their wheelchairs to keep up with all they do.

Invacare Corp.(800) 333-6900invacare.com

RowheelsThe Rowheels system propels a manual chair forward when the user pulls (similar to a rowing motion) on the handrim, and moves backwards when the user pushes. The result, Rowheel says, is fewer propulsion strokes and improved posture with better shoulder/back positioning. Rowheels are available in 22", 24", 25" and 26" wheel sizes. They fit most manual wheelchairs and can be used with ergonomic handrims.

Rowheels(608) 268-9670rowheels.com

TRAKThe TRAK tilt-in-space stroller-style wheelchair features easily adjustable seat depth and back height to dial in just the right combination of positioning and support for each child. The TRAK also is equipped with RESPOND seating that can be contoured specifically as needed. A sunshade and under-seat storage bag come standard with each wheelchair to make outings and activities more convenient and enjoyable for the whole family.

Leggero LLC(844) 503-5437leggero.us

7 Series7000 series aerospace aluminum, heat treated using ShapeLoc technology, is at the heart of the new 7 Series’ ultralight-weight frame that has thinner, lighter-weight tubing along with increased strength. The 7R allows quick back-angle adjustments throughout the day, while the 7RS has a fully rigid backrest and axle plate to further reduce overall weight. The new Freestyle Backrest System provides 360° of upper-body motion.

Sunrise Medical(800) 333-4000sunrisemedical.com

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manual wheelchair marketplace

TX Series 2The new TX ultralightweight chair provides the power and style of a rigid design with the convenience of a folding one. The titanium dual-tube TiFit frame offers dura-bility, while side-to-side folding provides a slim folded profile for easy transportation. The TX Series 2 is available in seat widths of 12-20" and seat depths of 14-20". Every TX2 is made specifically to accommodate and fit the sizing and needs of its particular and unique user.

TiLite(800) 545-2266tilite.com

WX2.5 WheelsThe continuous carbon fiber spokes of Topolino’s WX2.5 span the full diameter of the wheel to reduce stresses and create a wheelset designed for unparalleled performance. The WX2.5 is lighter than many other lightweight wheels, while offering greater lateral stiffness at the same time. It’s available in 24" and 25" diameters, in black with red or yellow accents. The WX2.5 fits standard .5"-diameter axles and is 4- or 6-tab handrim compatible.

Topolino Technology(203) 778-4711topolinotech.com

®

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Compatible with most manual chairs VISIT US AT WWW.ROWHEELS.COM OR CALL (608) 268-9670

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Medicare, VA and private reimbursement eligible

ad index

Adaptive Switch Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Amysystems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Clarke Health Care Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Convaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Freedom Designs/Invacare Corp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Leggero LLC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Medtrade . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Motion Composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Motion Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Numotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Permobil/TiLite . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Pride Mobility Products/Quantum Rehab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3, 18

ROHO Inc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Rowheels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Stealth Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Sunrise Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Thomashilfen North America . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Company Name Page #

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http://www.rowheels.com

COLLABORATE >> CULTIVATE >> INNOVATE

Produced by:

CONFERENCE OCT 31-NOV 3, 2016EXPO NOV 1-3, 2016 GEORGIA WORLD CONGRESS

CENTER ATLANTA, GA

A refreshed business strategy, a new revenue stream, a different approach…these can be your takeaways from Medtrade 2016! Ideas can be found around every corner of Medtrade. You’ll see the latest products

strategies, industry trends, and discover what others are doing in the conference sessions. It’s in one place, under one roof, ready for the HME industry to collaborate, cultivate, and innovate.

Register today at medtrade.com

TO MAKE CHANGES IN SOMETHING ESTABLISHED, ESPECIALLY BY INTRODUCING

NEW METHODS, IDEAS, OR PRODUCTS.

INNOVATE (v):IS IT TIME FOR SOMETHING NEW?

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August 2016 • Vol. 15 No. 8 Serving the Seating &...

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