June 2013 † Vol. 12 No. 6 Serving the Seating & Mobility...

June 2013 • Vol. 12 No. 6

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Serving the Seating & Mobility Professional

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4 mobilitymgmt.comjune 2013 | mobilitymanagement

june

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 offi ces. Complimentary subscriptions are sent to qualifying subscribers. Annual subscription rates payable in U.S. funds for non-qualifi ed 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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On the CoverContemplating optimal head positioning: It’s not always what it seems.Cover by Dudley Wakamatsu.

12 Ultralights: Th e Demise of K0009 From the elimination of the K0009 HCPCS code to ongoing funding challenges, the

ultralightweight wheelchair niche is in evolution. What does that mean for consumers

and the next generation of manual wheelchair technology?

18 cover feature Using Your Head Poor head positioning can cause problems with a wheelchair user’s visual fi eld, speech,

eating and other critical functions. But the reasons for poor head positioning can be

complex — as are the potential solutions.

volume 12 • number 6

What’s New Online: MobilityMgmt.comBetween monthly issues, keep up with breaking industry

news and track hot topics via Mobility Management’s Twitter

feed, now directly viewable 24/7 on MobilityMgmt.com.

Stay up to date on new articles, events, important research

studies and mainstream media coverage of assistive tech-

nology, right on Mobility Management’s homepage. It’s the

easy way to stay on top of trending industry topics at a

glance, no matter where your day takes you.

6 Editor’s Note

8 MMBeat

26 Marketplace: Ramps & Lifts

28 Classifi eds/Ad Index

30 Product Revue

24 Debuts This Month! New Discoveries Does power chair tracking technology help consumers to drive better? By Lois Brown & Michelle L. Lange

June 2013 • Vol. 12 No. 6

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Serving the Seating & Mobility Professional

contents

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A few years back, a popular book by Greg Behrendt called He’s Just Not That Into You sought humorously but pointedly to level with single women who make excuses for men.

To the woman who protests that her dream guy meant to call her, but got too busy to dial a phone, Behrendt responds, “The word busy is the relationship weapon of mass destruction. It seems like a good excuse, but in fact, in every silo you uncover, all you’re going to fi nd is a man who didn’t care enough to call. Remember: Men are never too busy to get what they want.”

Behrendt takes no prisoners when it comes to disavowing women of the excuses they dream up. Does your man stand you up? Behrendt replies, “Don’t you want the guy who’ll forget about all the other things in his life before he forgets about you?”

How about He must have lost my number, but I have his, so it’s OK to call him, right? (C’mon, we’ve all been there….)

“If you can fi nd him, then he can fi nd you,” Behrendt says. “If he wants to fi nd you, he will.…A man who wants to make a relationship work will move mountains to keep the woman he loves.”

The author’s generalizations don’t always apply — I recall a Matt Damon movie in which he lost a woman’s phone number because time travelers took it from him and burned it. But I believe the gist of the message: People (of both genders) make time for what is important to them. We make time to confi rm our paychecks have direct-deposited at the bank, don’t we?

Thus, I draw this conclusion: The Centers for Medicare & Medicaid Services (CMS) is just not that into us. Nor is CMS into our clients, also known as its benefi ciaries.

I don’t base this on just one thing, such as the Medicare competitive bidding program, which awards contracts to DME suppliers at such rock-bottom rates that it’s guaranteeing benefi cia-ries can only be provided the cheapest products. There’s also Medicare’s defi ant clinging to an archaic in-the-home rule. And funding cuts so deep that CMS should know — through research and common sense — that providers cannot supply the best-quality equipment anymore.

Now there is the elimination of the K0009 HCPCS code after fl urries of meetings that went nowhere (see the ultralightweight wheelchair update, page 12). CMS has eliminated this miscel-laneous code and thrown K0009 products — custom ultralights, standing manual chairs, fully featured bariatric manual chairs — into existing codes without altering the codes in any way.

This defi es logic. CMS created the “temporary” K0009 miscellaneous code to hold a few prod-ucts that didn’t fi t into other manual wheelchair codes. Now CMS has decided K0009 chairs do fi t into other codes after all? Is CMS saying it was wrong to create the K0009 code in the fi rst place?

Through its actions, CMS is not demonstrating that it believes DME and complex rehab tech-nology providers are an important of the healthcare continuum. Worse, CMS is also implying it doesn’t care much for the outcomes of its own benefi ciaries. CMS is supposed to advocate for its benefi ciaries. But then shouldn’t it, for instance, understand that it can only cut allowables so far without lowering the quality of the equipment it’s buying? And shouldn’t quality that’s tied to better clinical outcomes be a CMS goal, too?

CMS would possibly argue that it knows it can only cut funding so much, but hasn’t reached the bottom of the barrel yet. I’d retort, “Is your goal truly to provide bottom-of-the-barrel care and technology to your benefi ciaries?” I know there are good people at CMS, but the agency as a whole seems to have lost its focus, at least concerning DME and complex rehab technology.

The message of He’s Just Not That Into You is that people’s actions demonstrate what is most important to them. CMS sends a clear message every time it cuts funding, dictates which handful of suppliers its benefi ciaries can see, and reduces access to higher-quality technology. ●

Laurie Watanabe, [email protected]

CMS Is Just Not Th at Into Us (or Our Clients, Either)

Editor Laurie Watanabe (949) 265-1573

Associate Editor Cindy Horbrook (972) 687-6573

Group Publisher Karen Cavallo (760) 610-0800

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Director, Jenny Hernandez-Asandas Print & Online Production

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SECURITY, SAFETY & HEALTH GROUP

President & Group Publisher Kevin O’Grady

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President & Neal Vitale Chief Executive Offi cer

Senior Vice President & Richard Vitale Chief Financial Offi cer

Executive Vice President Michael J. Valenti

Vice President, Christopher M. Coates Finance & Administration

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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.

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mobilitymgmt.com

Volume 12, No. 6

JUNE 2013

editor’s note



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Discover the possibilities discovery tmax tilt-in-space Averaging a lightweight 35 lbs for the base, the tmax fits your choice of seating and need for easy adjustability.

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Contact your Sales Representative at 800 328 4058 to hear about the simplicity of our “one invoice” program — and schedule a patient evaluation today.

Visit www.OttobockUSMobility.com for the latest on new products like the Everyday Activity Seat and OBSS Ortho-Shape.

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Fixed or height-adjustable armrests with optional side panels

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Visitors to the homepage see three choices: “I’m a Consumer,” “I’m a Dealer” or “I’m a Clinician.” Each choice is followed by popular inqui-ries for each type of visitor: For example, in the Consumer section, you can fi nd a nearby dealer, register your wheelchair or fi nd help in choosing a product. Th e Dealer section enables providers to confi gure and order products, obtain product literature, or fi nd technical support. Clinicians can register for CEUs or view a PDAC classifi cation list.

In addition, registering and logging in off ers additional opportu-nities. For example, once consumers have registered, they can write reviews of Sunrise products they own.

Diff erent Levels of DetailsComparing products (up to three at a time) within a category is one of the site’s new functions that could appeal to consumers, clinicians and dealers alike. For instance, click to compare three Quickie rigid manual chairs — the Q7, GT and GP series — and discover that while

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The challenge of creating a Web site lies in the identities of poten-tial visitors. Whom exactly does a complex rehab site serve?

Consumers who use seating & mobility products? Clinicians who perform assessments and recommend solutions? Providers who build and sell the systems?

Yes!Th at was the task facing the Sunrise Medical team when it sought to

re-create SunriseMedical.com.

One Site, Many Types of UsersTh e new site, which launched this spring, seems designed to anticipate questions from consumers and professionals alike without over-whelming them. It’s easy, given the sheer volume of products alone, for manufacturer Web sites to become a deluge of parts numbers and product descriptions that need to be waded through. But Sunrise’s redesign recognizes the importance of being able to retrieve that information quickly without requiring a lot of extra navigation.

Consumers, Dealers, Clinicians: Meet the New SunriseMedical.com

all three frames are made of aluminum, the Q7 is transit approved, and the GP series chairs have slightly lower user weight capacities (250 lbs. vs. 265 lbs.).

Th at sort of information might be suffi cient for consumers, but for clinicians and providers who need more specifi cations, the comparison also shows sizes from seat depths to seat-to-fl oor heights and center-of-gravity adjustment diff erences. Th ere’s also a full list of options and accessories for each chair. Need to see diff erences in footplate choices, axle plates or caster wheels? No problem! (Yes, using the comparison feature to match products head to head can be rather addictively fun.)

Picture This LifestyleBut beyond this, SunriseMedical.com seeks to showcase the possibili-ties that personal mobility can off er. Sunrise’s Web development team has made a point of showing technology in real-life motion. A power chair (QM-7) at the lake? An early-intervention stroller (the new Voyage) cruising the mall? Th e JAY J3 back used by a fi sherman?

Yes. Sunrise’s new site serves three diff erent populations, but those photos of consumers living their lives will resonate with users and professionals alike. ●

—Laurie Watanabe

mobilitymgmt.com 9 mobilitymanagement | june 2013

Rift on TRAM Is a Medical Design Excellence Finalist

Mobility has a name.

Our new site is coming soon - visit numotion.com. 800.500.9150

United Seating & Mobility and ATG Rehab have come together to form one dynamic company: Numotion. With a strong local focus, we aim to be the most responsive and innovative company to do business with for all our customers – and a loyal and helpful partner that will move lives forward for years to come. It’s a nu day in mobility.

Rift on’s TRAM, a product that performs multiple transfer and mobility functions,

has been named a fi nalist in the 2013 Medical Design Excellence Awards competition, the manufacturer has announced.

Th e TRAM — now available in a low-base option (see page 30) — was introduced last summer and can be used to perform seated or sit-to-stand patient transfers, and for partial or non-weight-bearing gait training.

Th e Medical Design Excellence Awards (MDEA) were created “to recognize signifi -cant advances in medical product design and engineering that improve the quality of health-care delivery and accessibility,” according to UBM Canon, the business-to-business media company that runs the program. “Designed to focus attention upon the complexity of product development and to showcase examples of what can be achieved when it is well done, the MDEA celebrates the achievements of medical product manufacturers, their suppliers, and the many people behind the scenes — engineers, scientists, designers, and clinicians — who are responsible for the groundbreaking products that are saving lives and changing the face of [medical technology].”

Th e awards recognize diff erent product categories, including critical care and emer-gency medicine; general hospital devices and therapeutic products; surgical equipment, instruments and supplies; and rehabilitation and assistive technology, including HME.

Th e TRAM is the sole rehab/assistive technology category fi nalist in the seating & mobility niche. Other fi nalists include ResMed’s Pixi Paediatric Mask and Medtronic Diabetes’ mySentry Remote Glucose Monitor.

Final award results will be announced this month at a ceremony in Philadelphia. ●

The TRAM, manufactured by New York-based Rifton, has an optional built-in scale so clinicians or caregivers can check patients’ weights during the transfer process.

http://www.numotion.com


ANAHEIM, Calif. — By the time Permobil’s Power Trip pulled into

Southern California — the eighth stop this spring — its team of clinicians, sales reps, product managers and engineering special-ists had the road show routine down to a science. In just under two months, Permobil visited 17 venues across the country, from Miami to Northern California’s Bay Area, from Allentown, Pa., to Phoenix. Th e Power Tour even crossed the border to visit Vancouver, B.C.

At every stop — Power Trip was hosted at rehab facilities, providers’ offi ces, and hotel conference areas — Permobil displayed technology ranging from its pediatric and adult power chairs to an impressive array of electronics options. It was a chance for all stakeholders to come together, as providers,

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Cross Country: Permobil Takes Power to the People

clinicians, consumers and caregivers were invited to view product demonstrations, try out power chairs, and talk to product managers and engineering staff about switch systems that off er independent mobility to more consumers than ever, or power chair accessories that can make the ride more convenient, effi cient and enjoyable.

Southern California: The Power Trip pulled into Anaheim.

Southern California: Ever-evolving alternate driving controls make it possible for more consumers to independently operate their chairs.

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New Orleans: The obstacle course includes a layout of a hallway and bathroom.

chairs were showing another important char-acteristic. Th ey’d been driven tentatively by novices, expertly by providers and clinicians, and joyously by kids who were power chair users themselves, or their siblings. Permobil staff ers didn’t even wince as new drivers collided hard enough to dislodge pieces of the “hallway” or “bathroom” obstacles, and the chairs themselves kept on going. All in a day’s work on the 2013 Power Trip.

— Laurie Watanabe ●

Southern California: Mark Gingles of Aero Mobility gives the obstacle course a try.

were to test and sharpen driving skills while showing off the capabilities of Permobil’s chairs — their maneuverability, their agility, their ability to keep their balance over less-than-ideal surfaces. But in Anaheim, less than halfway into the Power Trip tour, the

Houston: Permobil’s Hymie Pogir discusses alternate driving controls.

Th ere was plenty of Permobil hospi-tality, as well as a catered lunch… but the biggest draw was the power chair obstacle course. It was created to simulate physical environments encountered by active users: Contestants had to drive through a narrow “hallway” and enter, turn around in and exit a very small “bathroom” with a standard-width doorway. Th en there were uneven surfaces to drive over, and speed bumps to overcome.

Th e obstacle course’s goals undoubtedly

Dallas: Clinicians are treated to a power chair demonstration.


Time to update your contact information: Rick Hayden is the new national director of sales & marketing for Icon Wheelchairs, based in Toronto. Icon manufactures the Icon A1 rigid manual wheelchair, which boasts the ability to “dial in” adjustments as needed… Andrew Pyrih has joined Pride

Mobility Products as its new senior VP of domestic sales. Pyrih will be working closely with Jay Brislin, VP of Quantum Rehab, “to unite the overall vision and sales

growth of the company’s product lines,” according to a news announcement… Congratulations to Greg Packer, who’s been promoted to president of U.S. Rehab. Packer joined VGM Group, U.S. Rehab’s parent company, in 2009. In addition to a long tenure in the HME industry, Packer also served three terms in the Kansas House of Representatives… Isis Pharmaceuticals has announced it’s beginning a Phase 2 study for infants diagnosed with spinal muscular atrophy. Eight patients will be participating in the study, which seeks to determine optimal dosages for ISIS-SMNRx, a drug administered directly into a child’s spinal fl uid. Isis Pharmaceuticals says the drug is “designed to intervene in the splicing of RNA to increase the production of a normal protein, SMN.” Families of SMA provided more than $500,000 in support to a University of Massachusetts research program that developed the drug now known as ISIS-SMNRx… Bussani Mobility Team, which provides wheelchair acces-sible vans, has opened a new location in Smithtown, N.Y. (and they have the celebratory ribbon-cutting photo to prove it!). Founder/President John Bussani said a growing customer base in the area led

briefl y…

to the decision to open a new offi ce. “The entire team at Bussani has worked hard for

Icon A1 wheelchair

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Rick Hayden

Andrew Pyrih

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nearly 40 years to help ease the transporta-tion challenges of people with physical disabilities and their loved ones,” he said. “We’re fully dedicated and we understand their unique needs. Perhaps that’s why many of the people who come through our doors become lifetime customers.” Bussani Mobility is headquartered in Bethpage, N.Y., and serves New York, New Jersey and Connecticut customers. ●

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This month, following previous postponements and multiple industry meetings with Centers for Medicare & Medicaid Services

(CMS) personnel that were ultimately futile, the K0009 HCPCS code offi cially died.

Defi ned as “Other manual wheelchair/base,” K0009 for many years had worked as a miscellaneous code for manual chairs that due to certain characteristics or functions did not appropriately fi t into another manual chair code.

Last year, CMS announced it was re-examining and recoding all K0009 products. CGS Administrators, the Jurisdiction C DME MAC, said in a message echoed by the other DME MACs: “Manufacturers ,will be required to submit a new coding verifi cation application to the PDAC for review and assignment of the correct code for products currently coded as K0009.”

With that decision, CMS was essentially indicating it wanted to clean K0009’s house.

Same Code, Very Diff erent Levels of FunctionCurrently, there are 64 power mobility HCPCS codes for power-oper-ated vehicles (aka, scooters) and power wheelchairs.

But for the last 20 years, the industry has been working with a rela-tive handful of manual chair codes, all introduced in 1993:

● K0001: Standard ● K0002: Standard hemi ● K0003: Lightweight ● K0004: High strength/lightweight ● K0005: Ultralightweight ● K0006: Heavy duty ● K0007: Extra heavy duty ● K0009: Other manual/wheelchair base

Not surprisingly, in the last 20 years, new technology — new mate-rials, new ways of working with them, clinical research on subjects such as optimal propulsion methods, even the escalating numbers of bariatric patients — has resulted in chairs with innovative new func-tions. But with the elimination of the K0009 code, manufacturers are now forced to place their chairs into other codes.

Some K0009 chairs will, as of this month, become K0005 chairs. Th at means not just more chairs in the K0005 code, but more disparity among K0005 off erings, as well.

“When you look at a K0005 code today,” says Rita Hostak, VP of government aff airs for Sunrise Medical, “the range of features and functions in that code is unbelievable — and to think that it’s all at one level of reimbursement is just astounding to me.

“You can have something that’s so very basic in that code that truly

UltralightUpdate: Th e Demiseof K0009With the Manual Chair Miscellaneous Code Eliminated This Month, Industry Experts Worry About Access

wheelchairs & funding

By Laurie Watanabe

http://www.tilite.com



would not meet the needs of the majority of individuals with spinal cord injuries, all the way up now to very custom made-to-measure product — and it’s all at the same price. Where can you go on the open market and say, ‘I want the highest-featured, most functional product that you carry, but I want to pay the same price as I would for the least functional, least durable product you carry?’”

Given that K0005 chairs — including ones that used to be K0009 coded — have the same allowables, and given that profi t margins for suppliers are so slender to start with, Hostak points out that suppliers will be fi nancially motivated to choose less expensive K0005s that will net them more profi t.

“CMS almost sets the program up to incentivize putting out the least-featured product,” she says. “Because why not? Th e supplier is going to get the same level of reimbursement.”

Josh Anderson, VP of product & brand management for TiLite, has a C5/C6 spinal cord injury. He’s 6'9" tall, self-propels a TiLite chair that’s coded K0009, and is the perfect example of a consumer who doesn’t fall within “average” consumer demographics.

In a March meeting in Baltimore with Center for Medicare Deputy Administrator & Director Jonathan Blum, Anderson says, “I was sitting right next to him. Th at was actually one of the reasons I went: Th e chair that I use cannot be duplicated as a K0005. We talked through all the measurements, how it aff ects my ability to get around. He looked right at me and seemed to understand what we were saying. All for naught. Frankly, it seemed like they made the decision a year ago.”

The Defi nitions of CustomDavid Lippes, CEO/chairman of TiLite, said one of the justifi cations for in essence getting rid of the K0009 code centers on diff ering defi -nitions of the term “custom.”

“I think I understand their thought process,” he says. “I don’t agree with it, but I think I understand it. CMS decided they had a pricing problem, not a coding problem, and this problem related to their understanding of the word ‘custom.’ Basically, only a custom product can be paid for under individual consideration based on MSRP, as opposed to having a fi xed fee schedule associated with it. And with respect to a made-to-measure product like TiLite, we are custom. Th ere’s a Congressional statute as to the defi nition of custom, and we fi t it. Th ere is a Medicare defi nition that they wrote that does not match the statute defi nition — and it’s that regulation they’re following, which we think is in error. “

Hostak says Sunrise faces a similar scenario with its Quickie Q7 active rigid chair: “Because it’s a custom-manufactured chair too, that product was coded K0009, and it now as of June 1 will be in the K0005 code. So we have a similar situation as TiLite because [the K0009 code] was based on it being custom. It was the custom process, that each one of these chairs is built one-off for the person based on those measurements.”

Lippes says the diff ering defi nitions for “custom” impacted other products in the K0009 category as well. While K0009 is oft en thought

of as a “custom ultralightweight chair” code, prior to June 1 the code also included standing chairs, chairs with specialized tilt, and bariatric chairs with tilt.

“Basically all these products — they’re getting paid for based on individual consideration,” Lippes says. “I don’t know why [CMS is] worried about this now and hasn’t been for the last 10 years, but they decided that these products can’t be paid for under individual consid-eration, and therefore they had no choice but to stick them in other codes.

“And we said OK, if you can’t pay for them that way — and we’re not sure at least when it comes to made-to-measure that you can’t — then let’s build some codes to refl ect the technologies, because there are all these reasons why these are unique from a clinical standpoint and a technology standpoint.

“Aft er all, codes are developed for the purpose of segregating tech-nology based upon clinical indications. So the Clinician Task Force spent literally hundreds of hours developing a 600-page report that provided evidence of the specialized nature, application and bene-fi ts of K0009-coded products. Based on this report, we asked CMS to work with us to develop these new codes. Th is, in eff ect, was our compromise — let’s build new codes that refl ect the technologies that have been developed over the last 20 years, and you (CMS), in turn, can resolve your pricing concern on a code-by-code basis. Th at, in my mind, would have been a balancing of interests.

“But CMS refused. Instead, they solved a pricing concern through coding. It’s poor logic.”

Anticipating Access ProblemsLippes was a member of the work group — which included members of NCART, NRRTS and the Clinician Task Force — that met repeat-edly with CMS over the K0009 issue.

Consumer access was another one of the topics that came up in relation to eliminating the K0009 code.

Hostak, who was also part of the K0009 work group, says, “We heard this from CMS staff when we were talking about the K0009 problems: ‘I hear you saying that if we take your product out of the K0009 code and we put it in this other code, that we’re going to create an access problem. I have people in my offi ce every week saying, “If you reduce my reimbursement, there’s going to be an access problem.” My experience is I reduce the reimbursement and guess what: Th ere’s not an access problem. So I’m having a hard time sitting here in this meeting and hearing you say there’s going to be an access problem when history tells me that’s just not going to be the case.’”

But Hostak is concerned that access will be jeopardized.“Speaking for Sunrise, we have a bariatric product that’s intended,

to accommodate patients with a weight up to 650 lbs.,” she says. “But it has rear-wheel adjustability, it has features and functions that are more like a K0005 wheelchair. So when [CMS] looked at it, they couldn’t put it in K0005, because the frame is going to need to weigh more than 30 lbs. if it’s going to accommodate a 650-lb. patient. Th e fact that the frame weighed more than 30 lbs. excluded that code

The Demise of K0009


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from being an option, and so they said based on how much the chair weighs and the patient weight capacity, it’s a standard extra-heavy-duty manual wheelchair. It’s no longer a purchased option that it was under K0009; it would now be a capped rental, included in Round 2 of compet-itive bidding, which clearly it was not when the bids went out.

“You look at that and think, ‘What supplier would ever provide that sort of product under capped rental, and especially in the competi-tive bidding program, where the reimbursement for that code is so signifi cantly less than the fee schedule?’ It will not happen.”

Lippes says he was told in a meeting that CMS indeed wanted to make sure access to former K0009 chairs wasn’t hurt — but questions how the agency can eff ectively monitor such a small number of products.

In 2011, Lippes notes, 6,500 K0009 chairs were supplied in the United States. Medicare paid for only 307 of them — though the agency’s elimi-nation of the K0009 code will also carry over to other payors.

“You’re going to make a decision that’s going to hurt the independence of all Americans who need these products when only fi ve percent of those people are Medicare benefi ciaries?” Lippes asks. “Ninety-fi ve percent of the people you’re going to hurt through this decision are not Medicare bene-fi ciaries, yet you’re still going to make this deci-sion? CMS simply must consider benefi ciaries of private insurers when making decisions like this.”

Anderson notes, “Th e folks that they’re moni-toring, it’s such a small group that how much are they really going to hear back? Th ere are thousands of people who are going to be aff ected this year, of which they’re going to see a very small percentage of them, even if [CMS] is monitoring it.”

Hostak agrees that CMS, even in eliminating the K0009 code, does not believe it’s causing or that there will be an access issue.

“Th ey’re not saying, ‘Th at’s not important for you to have,’” she says, referring to a high-perfor-mance manual chair for a client such as Anderson. “Th ey clearly would say, ‘You’re 6'9", you’ve got to have that. Th ere’s nothing available that’s an off -the-shelf product that’s going to meet your needs, so we acknowledge that.’ Th eir problem is, ‘We don’t think you need a unique code for that to happen, and we think we’re paying too much

http://www.SunriseMedical.com



For this story, Mobility Management contacted Jonathan Blum, Deputy Administrator & Director, Center for Medicare, and Laurence Wilson, Director of the Chronic Care Policy Group, for comment. At press time, no one at CMS had replied.

for that item under the K0009 code. Oh, and by the way, we oft en use a diff erent defi nition for custom than what was originally placed in the Social Security Act, because we had the option of either using Medicare’s defi nition of custom or the defi nition of custom in the Social Security Act. We chose to use our own, and based on our own defi nition, you’re not custom. Custom means you have to be so unique that you can’t be grouped for pricing, and clearly, you have an order form with a price on it, so it must be able to be grouped for pricing.’”

Underscoring the Need for a Separate Benefi tWhile the correlation certainly wasn’t intentional, the offi cial elimina-tion of the K0009 code happened at about the same time the industry was getting very good news: H.R. 942, the House bill that would establish a separate benefi t category for complex rehab technology (CRT), would soon be joined by a companion Senate bill introduced by Sen. Chuck Schumer (D-N.Y.). (At press time, the bill had not yet been introduced.)

Don Clayback, executive director of NCART, was in the work group that met with CMS about the K0009 elimination.

“We’d been working on that K0009 issue since last fall, and unfortunately we didn’t get what we wanted,” he says. “But I think it does underscore the whole challenge, which is to have policy-makers recognize that it’s specialized equipment, and it needs to be recognized as such. That is one of our main messages when I talk to folks: That our biggest challenge and our additional objec-tive is really to educate people on what CRT is, who uses it, how it provided the benefits it produces. Because without that base-line education, you really can’t develop policies and coverage and payment around these products.”

While Clayback acknowledges the tasks on CMS’s plate, he also believes eliminating the K0009 code wasn’t the best way to address what CMS obviously considers to be a problem.

“We understand CMS has a challenge to provide coverage and payment for all sorts of healthcare services and products,” he says. “Th ere has to be some structure, and they have to have certain poli-cies and try to standardize as much as they can in terms of that process.

“Th e challenge, though, is to fi nd the right balance, and in our opinion they’ve thrown this out of balance. We know we can capture the vast majority of products within the current coding structure. But at least historically, we’ve had this ‘other’ wheelchair code that covers those specialized wheelchair bases that just don’t fi t into one of those other codes.”

Realistically, Clayback says, there will always be a very small percentage of people with disabilities who have such specialized needs that they need a more individualized strategy for their assis-tive technology.

“You need to take the approach that we’re going to try and compartmentalize as much as we can within already established codes,” he says. “But we also recognize that there is no way we can have a code for every single item. So once we’ve identified and

coded, for example, 95 percent of wheelchair bases, we need to have another code or a set of codes that addresses these bases that can’t be grouped with other technology. If there’s similarity in terms of characteristics and how it’s applied, how it’s provided and the pricing and cost of it, you can group those things into indi-vidual codes. But where you have a lot of variance, where it doesn’t work for every wheelchair base — that was really the purpose of the K0009 code.”

Clayback said the work group tried to help CMS to fi nd a solution short of eliminating the K0009 code.

“Our conversations with CMS were ‘Th at’s how that code has been used and has been working. If you have a concern about that, there are really two options. One, change how that code is being administered; or two, create additional codes that take those specialized products and properly segregate them.’

“Th e third option, which is the one they took, is the wrong option — which is to say, ‘We’re just going to take these items and we’re going to cram them into an existing code that might have one simi-larity, but we’re going to ignore the eight other dis-similarities.’ Th at’s really what our continued challenge is: To fi nd solutions that meet a [CMS] concern, but that the solution or the change that CMS makes doesn’t undermine access.”

Ideally, Clayback says, CMS would be able to have a system streamlined enough to be effi cient, but one that doesn’t artifi cially force products into inappropriate codes.

“CMS is sometimes limited in what they can do, so I’m not saying these solutions are easy,” he notes. “But the solution isn’t to do the wrong thing. Th e solution is to look at the options that are available and either pick one that doesn’t damage access, or change some of the system so you can have an option that works for everybody and doesn’t undermine access.

“You certainly don’t take all the wheelchairs and put them into this individually considered code. We have to have some sort of system where we can categorize the majority of those products. Th at’s why you have the K0005 wheelchair and the E1161 manual tilt-in-space, and you have the Group 3 power wheelchair category. Th ere are certainly ways that you can address the vast majority of wheelchair bases and accessories. But in our minds, you’re always going to have that one other code that needs to be a catch-all for those low-utilized items that are important for people who have certain needs that can’t be met with one of those other chairs.”

Anderson points out, “Th e people that use this type of equipment absolutely need it to be functional. It’s not like they can get around in another fashion. Th eir level of function, such as mine, is dependent on that. And with that small investment, you’re contributing to society versus taking from society. I think it’s a fundamental diff erence.” ●

The Demise of K0009

news:H.R


Funding Watch: When Will Ultralightweight Chairs Be Recoded?Revamping HCPCS codes for durable medical equipment and

complex rehab technology can be long, drawn-out processes. The Centers for Medicare & Medicaid Services (CMS) put new codes

for wheelchair seat cushions into eff ect in 2004. After that, CMS tackled the power mobility segment: New K (i.e., “temporary”) codes have been used since 2006.

As CMS was laboriously expanding K0010, K0011, K0012 and K0014 into nearly 60 new power chair codes, we kept hearing that manual chair recoding would be next. They’re on the horizon. They’re slated to be done.

But in subsequent years, that chatter has all but stopped. So: Is recoding manual wheelchairs, including ultralightweight models, still on CMS’s radar?

New Codes in Our Future?“The answer to that is that CMS has not indicated any desire or willing-ness to modify manual wheelchair HCPCS codes at all,” says Rita Hostak, VP of government aff airs for Sunrise Medical.

“Dr. [Doran] Edwards, when he was the medical director for the SADMERC [Statistical Analysis Durable Medical Equipment Regional Carrier], spent a tremendous amount of time and eff ort meeting with the industry, doing research, understanding the diff erences in the tech-nology and the clinical applications, and had developed a very detailed and comprehensive proposal,” Hostak recalls. “He had taken what the NCART coding group had put together and — much like he did with the power wheelchair [recoding] — took it, analyzed utilization from a Medicare perspective and had worked up his own proposal. I think he got to a point where he was able to submit that to CMS and got basi-cally no traction.”

Then CMS changed contractors, and the newly named Pricing, Data Analysis & Coding contractor (PDAC) took over for SADMERC. “Dr. Edwards was gone,” Hostak says, adding, “Absolutely nothing has happened since then” regarding new codes for manual chairs.

So is recoding for manual chairs no longer on CMS’s radar?“It’s not in line anymore to be looked at,” Hostak says. “And actually I

think that CMS’s perspective around coding has changed, has morphed. It’s really quite diff erent than it would have been even fi ve or six years ago.

“Now CMS is trending more toward bigger buckets with a broader range: an array of technology within a given code. At least a decade ago or so, prior to HIPAA, there was defi nitely a recognition of techno-logical diff erences, clinical application diff erences, that sort of thing. Today, ‘It looks like a wheelchair, it feels like a wheelchair, it’s a wheelchair: Why do you need more than one code?’ is more of the mentality than what we would have witnessed a decade or so ago.”

Long-Lived “Temporary” CodesBy defi nition, K codes are temporary codes, stand-ins until permanent E codes are announced. The K codes for manual chairs have been standing in for a long time, indeed.

“The ultimate loser in this scenario,” Hostak says, “is consumers, for a

couple of reasons.“One is that the codes and the corresponding reimbursement for

most of the codes — the adult manual wheelchair codes, except for tilt — were created in 1993 based on technology that’s now 20 years old. So you take that code that had very specifi c technology that it was designed for, and now you’ve just kind of shoved products into those codes whether they really were similar or not.”

Hostak points out that even as newer, innovative products are forced into old codes, CMS historically hasn’t raised reimbursement rates. “But I think more importantly, because none of those codes were really well defi ned, what you fi nd is while the code was created with specifi c products in mind, it lacks the kind of specifi city and clarifi ca-tion as to how you have to qualify for that code. So much-less-featured items now fi t into that same code.”

Due to multiple years of fee schedule freezes, Hostak has noticed providers having “to move toward the less-featured products in order to be able to provide them under the current reimbursement. Consumers that are newly injured or have newly acquired mobility problems may not know what they’re missing. They may not be able to say, ‘Wow, 10 years ago I could have gotten something much better than this for the reimbursement rate.’

“But consumers that have had the technology for fi ve years, 10 years, 20 years, are coming back to get a replacement chair and are shocked to see what Medicare and in many cases Medicaid is going to allow them to have access to from a reimbursement perspective. So you have the access problem for the consumers.”

Future Innovations EndangeredWhile consumers are already suff ering as CMS continues to force new products into old codes without raising allowables to compensate for new technology, Hostak says wheelchair users will also suff er in another, less tangible way.

“It’s hard for a manufacturer to justify spending the R&D dollars to invest in innovation while knowing that their ability to get a HCPCS code and proper coverage and payment is minimal at best,” she points out. “So it’s not only causing a decline in what’s available in terms of features and functions for consumers, but it’s also created a huge barrier towards innovation. In a market of people with disabilities, inno-vation is really important.

“Keeping product design and product function and features in line with allowing them to be more active, more integrated into the community, returning to work, returning to school, having as normal a life as possible absolutely should be what everybody’s focused on. At the end of the day, if you can’t get paid for it, you can’t do it. Consumers are absolutely the ones that are being the most signifi -cantly impacted by it.” ●


If there’s a general truth in the “Everyone’s unique” world of seating & positioning, it might be this: Nothing is necessarily as it seems.

In a simpler world, if a client’s head were laterally fl exed or rotated, the answer would be “Just reposition his head!” But in reality, head-positioning problems might stem from issues with the pelvis, the lower extremities or the upper extremities.

Th at’s just one of the many challenges facing clinicians and ATPs seeking to provide their clients with optimal head positioning.

Where Do We Start?For this article, we enlisted the following experts:

● Lise Desharnais, physiotherapist, Queen Alexandra Centre for Children’s Health, Victoria, B.C.

● Jay Doherty, OTR, ATP/SMS, clinical education manager, Quantum Rehab, Exeter, Pa.

● Angie Kiger, M.Ed., CRTS, ATP, clinical education specialist, Sunrise Medical, Fresno, Calif.

● Gabriel Romero, director of sales & marketing, Stealth Products, Burnet, TexasOur fi rst question: During a seating assessment, what are some

indications that a client might have diffi culty with head positioning?All four experts indicated that even when a client’s head is not posi-

tioned optimally, the ultimate cause might lie elsewhere.“If head positioning issues present, be careful to not start there, but

fi rst assess the whole person and the seating,” Lise Desharnais says. She adds that there is a wide range of indications for head positioning diffi culties, including “tonic neck refl ex issues, scoliosis/kyphosis, passive ranges of motion at the neck, weakness, drooling, swallowing and eating disorders.”

Jay Doherty says his assessment begins as soon as he sees a client.“I start looking at them the moment I lay eyes on them,” he says,

“even if they’re transferring out of the car. You notice how they use their bodies — pelvis, lower extremities, trunk, head and neck, upper extremities. Do they move their head around, or does their head stay in a very similar position as they move? As they’re transferring, does the care provider support their head, or do they reposition their head a certain way during that transfer?”

It’s important to note such details and notice how other parts of the body are positioned — in part because even clients and caregivers might not be aware of how poor positioning elsewhere can aff ect

Determining the Cause of Poor Head Positioning Is Diffi cult…& Critical to Overall Seating Success

ATP Series

By Laurie Watanabe

http://www.stealthproducts.com


Look for head positioning equipment options in a complex rehab technology exhibit hall, and you’ll fi nd a wide array of hardware

and pads in diff erent sizes and shapes, capable of varying positions and movements to answer the needs of individual clients.

Look at those same choices through the eyes of the Centers for Medicare & Medicaid Services (CMS), though, and you’ll see some-thing entirely diff erent.

Rita Hostak, VP of government aff airs for Sunrise Medical (see her comments about the K0009 code and ultralightweight wheelchairs starting on page 12), points out ongoing funding challenges for head positioning. The issue is caused in part, she says, by CMS’s deci-sion to add the words “any type” to various code descriptors.

As an example of the eff ects of those changes, Hostak says, “I’ll just use the headrests because it’s my sorest spot. We’ve tried for 10 years to get a unique HCPCS code for the various arrays of head-rests. You can have a headrest that just has a single fl at pad that’s on a single piece of hardware that really is just there as a headrest if somebody reclines or tilts. Or you can have a very complex headrest with multiple pads, swingaway hardware, adjustable in multiple planes, that can hold and adjust and support the most profound child with tone issues and all sorts of things.

“Those fi t in the same code, same level of reimbursement. And the reimbursement is less than what it cost the supplier to acquire the parts.”

So suppliers can actually lose money by providing complex head-rests according to Medicare’s current allowables, and Hostak adds that consumers pay the price.

“I can assure you that the access to those devices just based on our utilization has been impacted,” she says. “To me, the individuals with the most profound disabilities are the ones impacted the most.” ●

ATP Series

A Funding Headache

head positioning.“Oft entimes clients and/or caregivers will report that the headrest

is not mounted properly, does not fi t, or simply is not working, and request adjustments or an alternative headrest,” Angie Kiger notes. “However, the actual issue is related to how the client is positioned in his/her seating system.”

“You start with the hips,” Gabriel Romero says. “But I fi nd out that a lot of the times, I can tell what the hips are doing by the head posi-tioning. And I can see if there are already some deformities or things that are happening based on how somebody’s head is positioned. Not only that, but I’ve seen some people positioned perfectly — the old ‘90°, 90°, 90°’ rule — who still had really poor head positioning because of a lot of variable factors, from diagnosis to fatigue.”

Common Diagnoses, Common ImpactsMaking head positioning even more complex is the wide range of diagnoses that can contribute to the problem.

“Medical conditions or mobility-related diagnoses that commonly relate to poor head positioning include muscular dystrophy, spinal cord injury, amyotrophic lateral sclerosis (ALS), cerebral palsy (CP),

acquired brain injury, muscle tone issues (hypertonia, hypotonia, or mixed tone), hydrocephalus or other cranial deformities,” Kiger says.

Poor head positioning can also threaten a wheelchair user’s ability to remain independently mobile.

“Another area to consider when discussing the impact of head posi-tioning and support is access to power wheelchair input devices such as head array, chin control, and sip & puff ,” Kiger says. “If the client’s head is not positioned well, he may not be able to independently control his power wheelchair or other technology devices.”

In addition, poor head positioning can cause its own array of physical challenges. In addition to the swallowing and eating prob-lems that Desharnais mentioned, Doherty says, “Is it aff ecting their breathing? Do they have a harder time speaking? It may be the volume of their speech that’s impacted, or the quality of their speech. Visual fi eld is going to be impacted.”

Clients with poor head positioning may also have diffi culty righting themselves if they begin to lean to one side.

“If you and I are leaning,” Doherty explains, “we can bring ourselves back to that centered position again. But someone with their head off to the side may have diffi culty… Th eir center may not neces-sarily be the same as our center.”

And Doherty adds that head positioning may even impact how wheelchair users are perceived by others.

“If someone has a head positioning issue, the perception of others may change in a negative manner,” he says. “Th ey look like they have a greater disability than they do because their head positioning is not optimal. So certainly there’s a social aspect to it.”

What Are the Rehab Team’s Goals?Every seating & mobility client presents uniquely, and diff erent clients have diff erent goals. So do their rehab teams.

Desharnais says, “Th e head support has to be integrated to the whole seating system. In the end though, I try to accommodate fi xed spinal deformities — for example, to have the head as level and func-tional as possible. It is all about the head, and really the eyes. So, if there is a fl exion deformity of the spine and neck, one may need to slide forward on the seat and slouch to get the head upright. Same with lateral curvatures: Aim to have a level gaze.”

While some clients do well with equipment that just supports their heads, Romero says other clients may want to work on strengthening their muscles to improve head positioning over time.

“When you’re looking at the therapy behind [head] positioning, a lot of times we say we have somebody that has fatiguing issues,” he says. “So we’ll just create a barrier instead of saying, ‘How can we use therapy on our side, and remove that barrier so they can gain some strength?’ You have kids with cerebral palsy that can gain that strength, and you want to be able to allow them to achieve that instead of creating a barrier.”

Talking to all members of the rehab team can help everyone to understand and consolidate goals.

“Th e client’s speech-language pathologist, respiratory therapist,

Using Your Head


nurse, recreation therapist, physician, etc., may be able to provide vital information regarding the impact of head positioning as it relates to activities such as feeding, vocal quality, communication, cardio-pulmonary status, participation in leisure activities, vision, hearing, behavior, and any other vital input for a specifi c client,” Kiger says. “Remember that during the seating evaluation you are only seeing the client for a snap shot in time, so lean on other team members to help you gain a clearer picture of the client.”

The Size of a FingertipOur heads can move in many directions, and that’s part of the head-positioning challenge.

“Your head moves in almost every plane of motion we have,” Doherty says. “Th e top of your spine is around the size of the tip of your fi nger, maybe a little larger. You’ve got a head that can be eight to 10 lbs., and it’s balanced on that point. All those muscles have to be working exactly right and together to balance the head and allow it to move. Th at’s a lot of weight to manage on that one little point.”

So how can ATPs assess how well that management and muscle balance is working?

“Assess using your hand,” Desharnais says, “Where and how much force is needed to position the head? Consider size and shape of the head.”

“Prior to determining if head positioning is an issue for a client, it is important to ensure that the client’s pelvis, trunk, and lower extremi-ties are properly positioned,” Kiger says. “Once the rest of the client’s body is in the most optimal position, it is important to next look at how his/her head is positioned. If the client is not able to maintain his head in neutral while sitting, take note as to which direction the client’s head tends to fall. During the seating assessment, it may be a good idea to use your hands to attempt to position the client’s head in the optimal position for him. By using your hands you are able to determine how much active movement the client has, if there is tight-ness in a certain area, the direction of the force and the amount of force needed to correct it, and the amount of support needed in terms of surface area.”

Romero agrees that other parts of the body can cause positioning problems that aff ect, but aren’t ultimately caused by, the head. For instance, many clients with head-positioning issues have poorly posi-tioned upper extremities as well.

“What’ll end up happening is the arms pull them in directions, and the head will end up following,” he says. “All the head needs is just a breath of wind to push it over. If you have an armrest that’s a little lower than the other, that’s the side that the head will be on.

“I’ve seen sometimes where the pelvis is fi ne — it’s positioned prop-erly, but a lateral on the side that the head was leaning to was out a little

http://www.surehands.com


ATP Series

“Does Th is Headrest Make Me Look More Disabled?”

From a seating & positioning standpoint, how the patient is positioned and “looks” in their wheelchair is critical. For many patients, their appearance is equally important. Unfortunately, some seating & positioning components are not aesthetically pleasing, but their purpose is to address a medical need. Recommending a piece of equipment that satisfi es the medical needs without appearing to be too obtrusive can be a challenge.

Manufacturers strive for that perfect combination of functionality and cosmetic appeal, which is the reason for the money spent on product design.

I think we have all heard from many of our patients that they would like to be seen as the person and not as the wheelchair. Those components that can extend beyond the body dimensions, like a headrest, need to be as functional and as inconspicuous as

possible. We have used a variety of headrest pads with removable hardware in diff erent dimensions that seem smaller or non-existent when viewed from the front, but are still in place for positioning as needed, and that has worked well for our patients.

— Rick Graver, ATP, President, Medtech Services, Reno, Nev.

I defi nitely have seen higher-functioning individuals not want to use a headrest. They have said they feel it makes them look more disabled, and they also say it frequently gets in the way getting into personal vehicles so they end up removing it permanently. Generally, unless their functional mobility is aff ected, people tend to want the least amount of support… no laterals, lower backs, etc. The less support you have, to them, the less disabled they look.

That said, we usually do more education. Most of the individuals who don’t use a head-rest are not tilting/reclining enough to get good pressure relief. When we explain the importance of pressure relief and have them tilt/recline to the necessary amount, they do say that they would use the headrest.

— Lauren Rosen, PT, MPT, MSMS, ATP/SMS, Motion Analysis Center Program

Coordinator, St. Joseph’s Children’s Hospital of Tampa

One of my biggest pet peeves is seeing kids in wheelchairs with gigantic headrests (I say they look like elephant ears)! Since my background is with kids, they often don’t complain about the “appearance” of the headrest, but I do know that this is a concern in the adult population.

— Amy Morgan, PT, ATP, National Clinical Education Manager, Permobil ●

With ALS clients, for instance, Romero says the rehab team has to help the family understand “the way they are now is not the way they’re going to be in weeks’ or months’ time. You show an ALS client [a more aggressive system] and they say, ‘No, no, no.’ But if you can show them a system that looks really clean, they may buy into that a little bit more.”

To deal with the complexities of achieving the right positioning, Romero says adjustability is key. “It’s important to have attaching hardware to the headrest pad that has a ball that you can rotate at any angle,” he explains.

Kiger adds that considering a range of components and options can also help to solve tough positioning challenges.

“Th ere are also components such as facial pads that come in a variety of shapes and sizes and can be added onto headrests, and diff erent types of headrest covers,” she notes. “Another key piece to the proper head support selection puzzle is mounting hardware — not only of the actual headrest, but also of the additional components. It is important to determine how much adjustability of the mount is needed for optimal positioning of the headrest, and how the mount will be attached to the chair. For example, if a client puts a great deal of force to the right side of the headrest, it might be worth considering off setting the hardware from midline to the right to absorb the force at a more direct angle.”

At the same time, Desharnais says, achieving a balance between technology and appearance is also crucial.

further. And all we needed to do was adjust the lateral in a little bit to keep the client more midline, which was helping the head stay midline.”

What Does Success Look Like?Head-positioning systems need to achieve multiple goals, so incorpo-rating multiple strategies can be helpful.

For instance, Doherty says, “A little bit of tilt or recline can go a long way to help with head positioning. Th ey can manage their head position a little bit better throughout the day by allowing gravity to help them keep their head upright. I always tell people you have to be careful of how much tilt you provide because we have a righting reac-tion, and because of that, the person could end up with more of a forward head position. So I usually don’t go past 10° on average. When you go past 10°, that’s a little further back, and a lot of people have a tendency to fl ex their heads forward to see where they’re going. You don’t want orthopedic changes to happen over time. I may tell them, ‘While you’re driving, tilt 5° or 10° if that allows you to hold your head up better. Th en when you get to where you’re going, tilt back a little bit further, put your head back on the headrest, and relax.”

Of course, many clients also can benefi t from head-positioning components — though getting clients to buy into a hardware solution can be tricky.

Romero says, “Th ere are some people that don’t want something to look aggressive, but they still need positioning. I’ve had some adults say about a system, ‘Oh, this is too much,’ but it’s really what they need.”

Aesthetics are an important consideration in a seating & mobility system, and that’s certainly true for head positioning. Human beings are wired to communicate both verbally and non verbally: We spend a lot of time making eye contact and studying facial expressions. It’s natural to want to

look attractive given how much time people spend looking at our faces.With that in mind, we asked three members of our editorial advisory

board if wheelchair users ever declined headrests because of their appear-ance…and if so, how they responded as healthcare professionals.

Using Your Head


The AXION Rotary Interface

Makers of the Savant Headrest

“Consider aesthetics and how others may perceive the head support,” she says. “Decrease bulk, and only use surfaces that are doing something.”

“You want the equipment to fi t the person,” Doherty says. If you’ve got a huge, wide headrest, you have to stop and ask, ‘What’s my purpose for it?’ And if there is a real, functional, positional purpose to it, then OK. But if there’s not — I’m a believer that less can be better sometimes.”

Aiming for Long-Term ImprovementRomero says younger children can sometimes show amazingly quick and dramatic improvements in head positioning once the seating team has incorporated solutions: “It’s like magic,” he says.

But much of the time, seeing real improvement is a slower process, he admits. “With some of these individuals, you’re only going to get an quarter of an inch or an eighth of an inch at a time when it comes to bringing them back to neutral. I’m talking about individuals where their ears are touching their shoulders, and that’s their positioning because they never had cervical stability. You can’t have 100-percent correction because of what’s happening with the neck muscles being extended or retracted. At times, you have seconds’ worth of rotation instead of minutes. You’re just looking for that minimal stuff : ‘OK, I was able to get an eighth-inch up, so I’m

stopping gravity now.’” Even if some improvement is visible right away, Doherty says

tracking a client’s progress is important.“Sometimes success is them going home and you following up

with them and hearing, ‘Hey, I can hold my head up all day long now!’ Sometimes you don’t necessarily know it at the appointment because maybe we were reducing fatigue. If it’s positionally, it’s a little easier to see sometimes because if they can achieve a more centered head align-ment, we can physically see the change. But sometimes it’s waiting and seeing — is the person fi nding it easier to do certain activities now? Is the person fi nding classes easier now because they’re not working so hard to hold their head up anymore? Can they see the board the whole time they’re in the classroom now?”

Kiger says, “Th e best way to determine if you have succeeded in creating the ideal head positioning system for a client is to work with the client and his team to monitor the client over time. If the client and/or team report that the client is happy, comfortable, does not exhibit any negative impacts from the system (e.g., respiratory issues, diffi culty with swallowing, pain, injury, skin breakdown, etc.), is safe, is functional while using the headrest, and the caregivers are able to eff ectively utilize the equipment, then it is likely that you have helped your client obtain the optimal head support system.” ●

http://www.symmetric-design.com

http://www.alumiramp.com


General clinical consensus is that tracking technology increases power wheelchair driving effi ciency… however, this has not been

proven in any formal manner. So a phase I study was conducted to deter-mine if, in fact, tracking technologies do increase driving effi ciency and to determine if further research is warranted.

What Is Tracking Technology?Tracking technology has been available on certain complex rehab power wheelchairs for a number of years. This technology is designed to keep the wheelchair “on track” without veering off course due to factors such as slopes and varied terrain.

How do chairs get off course in the fi rst place? After completing a turn, a power wheelchair’s casters are skewed, or facing to one side. When a Forward command is sent (by activating the Forward switch), these casters “pull” the wheelchair to one side before straightening out and moving the chair in a forward direction. The consumer must activate the Left and/or Right directional switches to compensate for this. Varied terrain, slopes and inclines also “pull” the wheelchair off course by turning the casters.

Tracking technology compensates for these infl uences and keeps the power wheelchair on the course dictated by directional switch inputs. Several distinct technologies are used to achieve this. This tracking tech-nology varies in design, but shares the same goal of increasing driving effi ciency, particularly for consumers who use alternative access methods rather than a joystick.

Who Can Benefi t from Tracking Technology?Many people with physical disabilities are unable to self propel a manual wheelchair, control a scooter or use a standard joystick on a power wheelchair. In this case, a variety of alternative access methods is avail-able. Most of these alternative access methods use switches.

Each switch activation moves the power wheelchair in a specifi c direc-tion. Typically, the consumer uses switches to move the wheelchair Forward, Left, Right and Reverse. If the consumer is able to activate more than one switch at a time, a diagonal movement is achieved (e.g., acti-vating Forward and Left results in diagonal movement between these two discrete directions). Switches can be placed in just about any posi-tion on the body where the consumer has control (e.g., hands, head, feet). A wide variety of switches is also available, from mechanical (e.g., plate and pneumatic) to electrical (e.g., proximity and fi ber optic).

Improving effi ciency in driving a power wheelchair is measured in decreased switch activations and decreased time to drive from one loca-tion to another. This is very important for consumers driving power wheelchairs, particularly with alternative access methods.

Reducing switch activations and time has many benefi ts for consumers. Physically, less motor eff ort is required, which saves energy and reduces fatigue. For consumers with conditions such as multiple sclerosis, saving energy is vital, as excessive fatigue can lead to loss of function.

For consumers with conditions that lead to increased muscle tone — cerebral palsy, traumatic brain injury — increased motor eff ort can lead to a further increase in muscle tone and resultant decrease in function. For

consumers with muscle diseases — muscular dystrophy, spinal muscular atrophy, ALS — excessive motor eff ort leads to muscle fatigue and can limit the amount of time the consumer is able to drive. Reducing the amount of time it takes to get from location A to location B is critical for consumers who are students and need to get to that next class on time or who are employees and have to move about the workplace in a timely manner.

The Study ProtocolA protocol was developed and followed on June 20, 2011. A course was marked out on a smooth, level surface — a gym fl oor — with tape.

Four trials were completed. One volunteer (18-year-old female, no motor, sensory or cognitive limitations) drove in each of the four trials. Invacare power wheelchairs with G-Trac tracking technology were chosen, as the tracking feature on the chairs can be turned on and offwith a programmer, allowing the same chairs to be used throughout the trials. Two study coordinators were present: One coordinator digi-tally recorded and timed each trial, and one coordinator recorded switch activations.

The fi rst trial was with a mid-wheel-drive power wheelchair (Invacare TDX SP) and three AbleNet Jelly Bean mechanical switches (Forward, Left, Right) on a tray. Driving parameters were programmed and remained the same throughout the fi rst trial. The time to complete the course was recorded, as were the numbers of activations of each switch.

For each trial, the volunteer wheelchair user completed the course three times without tracking technology and three times with tracking technology. The numbers of switch activations for each of the three runs were averaged, and the averaged results were compared for course completion with and without tracking.

The second trial used the same mid-wheel-drive power wheelchair, but with a head array. The third trial used a front-wheel-drive power chair (Invacare FDX) with three switches on a tray. The fourth trial used the same front-wheel-drive power chair with a head array.

The Observed ResultsComparisons of averaged switch activations required to complete the course showed that signifi cantly fewer switch hits were required when tracking technology was activated (57 to 76 percent less). Comparisons of average course completion times also showed that signifi cantly less time was required when tracking technology was activated (38 to 52 percent less).

Discussion for Future StudiesThis project was presented at the 2012 RESNA conference in Baltimore. The participants had a number of comments and suggestions for future eff orts.

The subject of this study completed the course fi rst without tracking and then with tracking, so participants were concerned that learning had improved effi ciency. Future research should vary the presence of tracking technology.

It was also suggested that more subjects be utilized. The subject was asked to move through the course while keeping a

blue line of tape on the fl oor in the center of the wheelchair. Participants suggested instead using parallel lines of tape that the wheelchair would

Tracking Technologies: A Phase I Study to Validate Effi cacy

By Lois Brown, PT, ATP, & Michelle L. Lange, OTR, ABDA, ATP/SMS

new discoveries


drive between, and to include an error count of how many times the wheelchair went over a line.

Participants also suggested that a longer straightaway and diff erent angles be included in a course (the study course included only 90° angles).

Applying These Results to Your ClientsIf you are working with a consumer who would benefi t from tracking technologies, funding may be an issue if the tracking technology is not a standard feature. You could set up a course and compare driving effi ciency with and without tracking to include in your documentation, using similar strategies to those in the study.

Tracking technology does, in fact, increase driving effi ciency by reducing compensatory switch activations and time required to move between locations. This effi ciency is critical for consumers, as driving effi -

ciency reduces motor eff ort, energy expenditure and can prevent fatigue, loss of function and increased muscle tone. ●

Turning speed was reduced from 20 to 15, and turning acceleration from 15 to eight. The head array was over-responsive in turning using the same driving parameters as three-switch driving. The same parameters were used for all six runs below.

MWD, G-Trac On, Head Array

MWD, G-Trac Off, Head Array

Trial 2: MWD, Head Array

• Forward: 58% fewer switch hits with G-Trac• Left: 79% fewer switch hits with G-Trac• Right: 71% fewer switch hits with G-Trac

• Combined average: 69% fewer switch hits• Time average: 47% less time

Driving Parameters• Forward Speed: 20• Forward Acceleration: 15• Forward Braking: 45• Turning Speed: 15• Turning Acceleration: 8• Turning Deceleration: 45• Tremor Dampening: 20• Power: 100• Torque: 36

Comparison

Trial 1: MWD, 3 switches on tray




Comparison

Minimum number of switch activations to complete course:• Forward: 9• Left: 4• Right: 4

FWD, G-Trac On, 3 Switches on Tray

FWD, G-Trac Off, 3 Switches on Tray




Comparison

Trial 3: FWD, 3 Switches on Tray

FWD, G-Trac On, Head Array

FWD, G-Trac Off, Head Array




Comparison

Turning Speed was reduced from 20 to 15 and Turning Acceleration from 15 to eight. The Head Array was over-responsive in turning using the same driving parameters as three-switch driving. The same parameters were used for all six runs below.

Trial 4: FWD, Head Array

Final Summary:

Protocol available upon request.

Trial 1: MWD, 3 switches on tray• 57% fewer switch hits• 38% less time

Trial 2: MWD, head array• 69% fewer switch hits• 47% less time

Trial 3: FWD, 3 switches on tray• 76% fewer switch hits• 52% less time

Trial 4: FWD, head array• 73% fewer switch hits• 48% less time

Michelle L. Lange is an occupational therapist in private practice in Denver.

Lois Brown is the rehab clinical education specialist for Invacare Corp.


Armada RampThis modular ramp system is engi-neered to be extremely light and fl exible while being easier than ever to install. It can be moved or reconfi gured when the consumer changes homes. Constructed of welded high-strength aluminum alloy, ramp sections are 36" wide in 4', 6', 8' and 10' lengths. Platforms are 5x5', with custom sizes available.

Alumiramp(800) 800-3864alumiramp.com

AL160 Lift Made to be small but strong, the AL160 Profi le features an open platform design and a simple silhouette that ensures a clear rear view. The automatic hold-down foot secures virtually any scooter with a wheelbase up to 42". Using a Class I hitch, the lightweight AL160 is ideal for compact cars.

Harmar(800) 833-0478harmar.com

Pathfi nder Lift This sleek, fully reversible design can be used for residential or commercial applications. The ADA-compliant lift has a minimal number of moving parts for easy operation and a compact footprint. Features dual fl ip-up armrests, submersible remote handset, battery and charger.

Aqua Creek Products(888) 687-3552aquacreek.com

Highlander Lift With smooth lifting and a small footprint, the Highlander RPL (residential platform lift) adapts to elevation changes up to 6' high for porches, decks and below-level garages. It has a 750-lb. weight capacity and is virtually maintenance free indoors or out. Commercial series lifts have up to a 14' rise.

Harmar(800) 833-0478harmar.com

Out-Sider Lift This platform vehicle lift for scooters and power chairs is now lighter, stronger, smoother, more adjustable and easier to use. It’s available in three models with two platforms: ASL-250A with Hold-Tite Foot for scooters, and ASL-250HTP with Hold-Tite Arm for power chairs. The ASL-250B secures either scooters or chairs. Platforms are 28.5" wide.

Bruno Independent Living Aids(800) 462-0664bruno.com

Jasmine Lift This premier full-body lift is loaded with innovative features for optimal functionality and safer patient handling up to a 500-lb. weight capacity. It features a rotat-ing 360° six-point hanger bar and 16.4" minimum height range. A battery-powered boom and base make Jasmine easy for caregivers to walk behind while wheelchairs are accommodated up front.

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

ConvertaStepThe ConvertaStep platform — approximately 6x3' — sits at the bottom of existing steps and remains fl at when not in use so able-bodied visitors can use the steps unimpeded. When needed, the ConvertaStep lifts wheelchair and user (up to 750 lbs.) up and over the steps.

ConvertaStep(260) 969-8645convertastep.com

Reliant Lift The full-body Reliant lift line is designed primarily to reduce caregivers’ back injuries while ensuring secure handling for pa-tients up to 450 lbs. Reliant lifts are available with manual or power bases, and manual hydraulic or power lifts.

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

lift s & ramps marketplace

INDEPENDENCE SERIES

comfortcompany.com pviramps.com

PLUG N PLAYRemovable “quick charge” lithium battery is available with every Independence lift. No wires and no lengthy installation, just unbox and go!

Independence has never been so easy.

The Independence Series includes four models to accommodate any scooter or power wheelchair specifications.

Introducing the

1.800.564.9248

http://www.pviramps.com


INDE2 Lift TrekAway Independence Series platform lifts are fully automatic, with simple operation and a 350-lb. lifting capacity. The Inde-pendence compatibility calculator ensures the right match between lift and vehicle/mobility equip-ment. A wide range of accessories enables consumers to customize the lift to meet their individual needs.

Prairie View Industries(800) 554-7267pviramps.com

Modular XP Ramp SystemUnique confi gurations of any length are easily accomplished and installed thanks to pre-made ramp sections in 4' to 8' lengths. Turns are available in 45°, 90° and switchback styles. Includes a limited lifetime warranty.

Prairie View Industries(800) 554-7267pviramps.com

Commander 400This new exterior lift is designed to off er maximum durability and smart serviceability in a system that is easy to use and quick to load/unload. The lift features water-resistant electronics, 2-axis/3-axis and gatekeeper con-fi gurations, telescoping mounting brackets and a 400-lb. weight capacity.

Pride Mobility Products(800) 800-8586pridemobility.com

Trus<T>Lift With more than 10,000 instal-lations to its name, Trus<T>Lift vertical lifts are made to provide safe, reliable and trouble-free access to homes, businesses and public facilities. They can be easily installed in new and existing buildings, and plug into standard 110-volt/15-amp outlets. A baked-on powdercoat fi nish endures tough weather.

Ram Manufacturing(800) 563-4382trustram.com

Multi-Fold RampsFor consumers who need to tra-verse entrances or small staircases inside and outside, these highly durable Multi-Fold ramps off er portable convenience. They’re available in 6', 7' or 8' lengths at 600 or 800 lbs. , and at 500 lbs. for 10' lengths.

Pride Mobility Products(800) 800-8586pridemobility.com

Wall Lift sBoasting a compact design for tight areas, these wall lifts are designed to be ideal for access-ing tub, shower, commode or changing table in the bathroom. Featuring a telescoping boom arm that rotates 180° to 320° with the addition of extension for greatest fl exibility, the lifts have a patient weight capacity of 320 lbs.

SureHands Lift & Care Systems(800) 724-5305surehands.com

lift s & ramps marketplace

Abilities Expo. . . . . . . . . . . . . . . . . . . . 29

AlumiRamp.. . . . . . . . . . . . . . . . . . . . . 23

Bruno Independent Living Aids. . . . . 31

Comfort Company/PVI. . . . . . . . . . . . 27

Harmar. . . . . . . . . . . . . . . . . . . . . . . . . . .2

Invacare Corp.. . . . . . . . . . . . . . . . . . . . .3

NuMotion. . . . . . . . . . . . . . . . . . . . . . . . .9

Ottobock. . . . . . . . . . . . . . . . . . . . . . . . . .7

Out-Front. . . . . . . . . . . . . . . . . . . . . . . .11

Permobil. . . . . . . . . . . . . . . . . . . . . . . . 32

Pride Mobility Products/. . . . . . . . . . . .5Quantum Rehab

SKYLINK Group.. . . . . . . . . . . . . . . . . . 28

Stealth Products. . . . . . . . . . . . . . . . . 19

Sunrise Medical. . . . . . . . . . . . . . . . . . 15

SureHands Lift & Care . . . . . . . . . . . . 21

Symmetric Designs. . . . . . . . . . . . . . . 23

TiLite. . . . . . . . . . . . . . . . . . . . . . . . . . . 13

advertisers’ index Company Name Page #

http://www.otodor.com

San JoseNovember 22-24, 2013

San Jose Conv. Center

Los AngelesFeb. 28-Mar. 2, 2014

Los Angeles Conv. Center

AtlantaMarch 14-16, 2014

Georgia World Congress Cntr.

New York MetroMay 2 - 4, 2014

New Jersey Conv. & Expo Center

ChicagoJune 28-30, 2013

Schaumburg Conv. Center

HoustonAugust 2-4, 2013

Reliant Center

BostonSeptember 20-22, 2013Boston Conv./Exhib. Center

http://www.abilitiesexpo.com


Low-Base TRAM Rifton’s TRAM is now available with a lower base (4.25" tall vs. a 6.75" standard height) featuring smaller casters so it can slide under beds for easier transferring. Operable by one attendant or caregiver, the low-base TRAM can lift a client out of bed and into a standing position, then support partial or non-weight-bearing ambulation to achieve early mobility. The TRAM can perform seated and sit-to-stand transfers; an optional built-in scale is available.Rifton (800) 571-8198rifton.com

Zen Lift Available in two weight capacities, the Zen lift is a lightweight platform-free lift and carrier for mobility vehicles. A mounting bracket with a triangular docking bracket attaches to the scooter or power chair. The E206 model (145-lb. lifting capacity) uses a Class 2 hitch, while the E207 model (400-lb. lifting capacity) uses a Class 3 hitch.Merits Health Products Inc. (800) 9MERITSmeritshealth.com

Trus<T>Lift 750With a 750-lb. weight capacity, this new lift can handle scooters and power chairs plus their users — and perhaps even caregivers as well. Despite the high weight capacity, the 750 plugs into standard 110-volt, 15-amp sockets. The lift can travel up to 14' in height, and the “Zero Load Start” feature uses less energy and produces less strain on the mo-tor for longer motor life and more consistent operation in colder weather. Soft Touch controls are easy to use thanks to buttons with a large surface area that require less strength and force to operate.RAM Manufacturing Ltd.(800) 563-4382trustram.com

product revue

Quickie Q7 EnhancementsSunrise Medical has unveiled 12 product enhancements for its ultra-lightweight Q7 adult rigid manual chair, including a transit option at the Q7’s full 265-lb. weight capacity. There are more options for center-of-gravity settings to allow more refi ned tuning according to each user’s needs, a new GT Caster Setting for more customization opportunities, and four new frame colors (matte black, matte green, candy purple and bead blast, a matte fi nish on raw aluminum).Sunrise Medical (800) 333-4000sunrisemedical.com

Wheelchair Travel CaseAirplanes, trains and cars can be damaging environments for wheelchairs. This new travel case, with internal dimensions of 12x26x31", is designed to off er both protection and convenience for travelers taking their wheelchairs with them. The bags are made of polyester with padded walls and zippered expansion pockets. Internal straps hold folded chairs in place, and heavy-duty roller wheels and a telescoping handle make it easier to get the chair from place to place.Troy Technologies (877) 928-8770travelwheelchair.net

Q. What Do You Call America’s Best Outside Vehicle Lift… After it’s been Redesigned to be Lighter, Stronger and Smoother?

A. The Out-Sider ®!

Bruno Independent Living Aids1-800-462-0664 • www.bruno.comcode: MOBMGT0613

Widest Standard Platform in the Industry

Improved Swing-Away Optional SimplifiedBrake Light

28 ½”

Lots of Improvements!

Plus many more!

®

http://www.bruno.com

While it may be the sincerest form of fl attery, imitation does not equal innovation. When it comes to comfort, don’t take chances. Developed in conjunction with the original Corpus® designer–world-renowned Swedish

seating expert Bengt Engström–our Corpus 3G incorporates the latest in ergonomic design for comfort beyond comparison. Trust the original. Genuine Corpus only from Permobil.

permobil.com

http://www.permobil.com

June 2013 † Vol. 12 No. 6 Serving the Seating & Mobility...

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Transcript of June 2013 † Vol. 12 No. 6 Serving the Seating & Mobility...