November 2012 • Vol. 11 No. 11

mobilitymgmt.com

Serving the Seating & Mobility Professional

www.OttoBockUSMobility.com

Adults, Kids & Everything In BetweenYour unique needs are our priorityNUTEC Seating is a highly customizable and adjustable seating system with unlimited options. From sizing and positioning to color and personalized embroidery, you can rely on our experts—like Klaus Birkholz—to make sure your patients’ needs are met.

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4 mobilitymgmt.comnovember 2012 | mobilitymanagement

november

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, 14901 Quorum Dr, Ste. 425, Dallas, TX 75254, email MOBmag@1105service.com or call (847)763-9688. POSTMASTER: Send address changes to Mobility Management, 14901 Quorum Dr, Ste. 425, Dallas, TX 75254. 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 CoverChildren with spinal muscular atrophy experi-ence accelerating muscle weakness… but their intelligence can give ATPs the chance to try creative options. Cover by Dudley Wakamatsu.

14 Balancing Loss & Gain Working with amputees requires knowledge not just of current mobility needs,

but also how the loss of a limb will impact the client’s positioning and mobility

in the future.

18 cover feature SMA: Keeping Options Open The progression of spinal muscular atrophy patients can challenge an ATP’s goal

of optimizing function and independence. PLUS: Growing up in an American

accessibility revolution.

volume 11 • number 11

What’s New Online: TheMobilityProject.comCheck out the Enabled Life section on TheMobilityProject.

com for ways that wheelchair users, their families and care-

givers can get the most out of life every day. Recent stories:

How occupational therapists work with bariatric clients to

improve quality of life; why anyone who independently

propels or operates his or her chair should consider wheel-

chair dancing; and understanding the relationship between

prostheses and wheelchairs.

6 Editor’s Note

7 MMBeat

24 Another Opinion

25 Clinically Speaking

27 Product Revue

28 Marketplace: Lift s & Ramps

29 Classifi eds/Ad Index

30 CMS Update

mobilitymgmt.com

contents

www.OttoBockUSMobility.com

Jacqueline is tickled pinkJacqueline and her Skippi roll the halls in styleAdjustable and confi gurable, the Skippi is tailored to Jacqueline’s needs. She stays engaged and active with friends and family — even her cheer squad!

To get details on clinical application and assessments, go to OttobockUsMobility.com. Then, click on the Jacqueline and Skippi story to request a free case study. Or call your sales rep at 800 328 4058.

6 mobilitymgmt.comnovember 2012 | mobilitymanagement

Since this is our November issue, I thought I’d take a cue from the season and mention some things I’m thankful for as we say good-bye to 2012…along with my accompanying wishes

for 2013: ● I am thankful for the accolades and higher profi le enjoyed by London’s Paralympic Games, which focused spectators’ attention on athletes’ abilities rather than on their disabilities. Ironically, while many Paralympic competitions were sold out, it may actually have been easier to catch the live event in London than to watch it on TV. For instance, while NBC covered the Olympic Games in excruciating detail, it devoted only a few short “highlight” hours to the Paralympics. A plea to NBC, who also has American broadcast rights to the 2014 Winter Paralympics in Sochi, Russia, and 2016 Summer Paralympics in Rio de Janeiro, Brazil: Give us a real chance to root for all of our sports heroes. I bet you’d be surprised by how many tune in.

● I am thankful for several encouraging signs from the spinal muscular atrophy (SMA) front (see the article starting on page 18). While I was researching this month’s cover story, news broke that a bill that would create a National Pediatric Research Network that would award grants to study rare diseases such as SMA. A week later came news that Repligen Corp. had started a phase 1b clinical study of a drug called RG3039 that could potentially treat SMA. The month before, Ben Mattlin, an NPR commentator and writer, released his autobiography: Miracle Boy Grows Up. Sure, it might all be a coincidence, but it’s hard not to hope that the rise in SMA awareness and funding will lead to something very good. And sooner than later.

● I am thankful to all the complex rehab technology providers, clinicians, ATPs, mobility dealers, manufacturer representatives and other industry experts who have shared their knowledge this year on everything from environmental accessibility to arm positioning to HCPCS code changes to the challenges of serving amputees (see the story beginning on page 14). It’s great to be an expert, but great and generous to take the time to share one’s hard-won knowledge with others. With every year, I hope healthcare professionals at large and consumers in general give you your proper dues and respect as critical parts of the healthcare continuum.

● I am thankful for the ongoing progress to create a separate benefi t category for complex rehab technology. The folks who have worked on this — from writing the position papers and sorting through HCPCS codes, to inviting members of Congress over for hands-on demon-strations of a day in the life of an ATP — do so in their "free time," which translates to a lot of late nights and weekend e-mails. Recognizing complex rehab technology as its own science and practice is a no-brainer. May even more people see the light next year.

● I am thankful to all who have supported TheMobilityProject.com, our consumer-targeted Web site that debuted in March. As of this writing, we’ve surpassed 2,500 Facebook “likes,” with readers across the country and around the globe.

Incidentally, the birth of The Mobility Project means we now have twice the need for inter-views, expert insight, commentary, etc. Thank you to those who have answered our call…and with incredible cheerfulness. More than a decade ago, you supported a new magazine called Mobility Management, and we owe our success and existence to you. Now, we also owe The Mobility Project’s success and existence to you, too.

● Finally, my gratitude to this year’s editorial advisory board members — also a group that takes my calls and answers my e-mails much more good-naturedly than I deserve. I have much to be thankful for, thanks to you. ●

Laurie Watanabe, Editorlwatanabe@1105media.com

Looking Back & Ahead in a Season of Th anks Editor Laurie Watanabe

(949) 265-1573

Editorial Fax (949) 265-1528

Art Director Dudley Wakamatsu

Director, Jenny Hernandez-Asandas Print & Online Production

Production Coordinator Charles Johnson

Director of Online Marlin Mowatt Product Development

Group Publisher Karen Cavallo (760) 610-0800

National Sales Manager Caroline Stover (323) 605-4398

Sales Assistant Lynda Brown (972) 687-6710

Advertising Fax (866) 779-9095

HME MEDIA GROUP

Group Publisher Karen Cavallo

Senior Director, Bill Ellis Audience Development

Director, Margaret Perry Audience Development

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

Vice President, Erik A. Lindgren Information Technology & Application Development

Vice President, David F. Myers Event Operations

Chairman of the Board Jeff rey S. Klein

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: FirstinitialLastname@1105media.com

Dallas Offi ce (weekdays 8 a.m. - 5 p.m. CT)Telephone 972-687-6700; Fax 866-779-909514901 Quorum Drive, Suite 425, Dallas, TX 75254

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mobilitymgmt.com

Volume 11, No. 11

NOVEMBER 2012

editor’s note

mobilitymgmt.com 7 mobilitymanagement | november 2012

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Lowe’s Launches Home Ramp Program

Laurie King Joins Ottobock’s Sales ForceOttobock has added Laurie King to its Mobility Solutions

sales team, the positioning and mobility manufacturer has announced.

King earned her associate of science degree, physical therapy assistant, from Broward County Community College, a bachelor’s of health administration from Florida Atlantic University and a master’s of manage-ment information systems from Nova Southeastern University. She has worked as a physical therapy assis-tant, was president of South Florida Rehab Services,

and was orthopedic device medical manager for Össur Americas, which manufactures prosthetics, braces and supports.

King was most recently a sales consultant for Cardinal Health in West Palm Beach, Fla.

“Laurie’s extensive background in physical therapy and medical device sales are strong assets that we’re confi dent her customers in Florida will appreciate,” said Matt Swiggum, Ottobock VP of Mobility Solutions, U.S. Healthcare. King will be calling on customers in Florida. ● Laurie King

Lowe’s new Gatehouse Custom Access Ramp System off ers modularity and customizability to a variety of spaces and needs.

The popular retailer perhaps best known for selling appliances, fl ooring, tools, hardware and other home-improvement products

has launched a home accessibility ramp program — with plenty of accessibility resources to back it up.

Th e Gatehouse Custom Access Ramp System, according to a Lowe’s news announcement, was created “to improve home access without sacrifi cing style.”

Th e announcement added, “Th is new off ering provides fami-lies, caregivers and professionals an aff ordable, do-it-yourself ramp product that’s now available nationwide on lowes.com/ramps.”

Th e ramp system will also be available in select Lowe’s retail stores.Lowe’s describes Gatehouse ramps as “a unique solution” that

combines “the customizable style of a custom-built wood ramp and the easy installation of a traditional aluminum modular ramp.”

Th e ramp can be installed for permanent use, or just temporarily. Because Lowe’s off ers straight, right, left and U-turn sections, ramps can be customized to fi t the needs of virtually any home. Lowe’s says the system’s fl exibility also makes it suitable for commercial applications.

New Resources for Consumers & CaregiversTh e Gatehouse ramps are complemented by a Lowe’s Web site called Accessible Home, which houses an impressively wide range of articles arranged conveniently by categories (e.g., Safer Bathing, Mobility Improvements, Grip & Reach Assistance) and Tips by Area (e.g., Entry & Access, Kitchen, Lighting, Bath, Landscape). Within those topics, the Web site has collected related products, such as — in the Mobility Improvements category — wider doors, off set hinges and accessible sinks.

Since this is Lowe’s, there is also a do-it-yourself section, which includes articles on subjects such as building a ramp. “What type of

assistive device does the person use?” the ramp article asks. “Who’s the primary user? Will the person’s abilities change?”

Th e site also includes universal design articles and products that encourage consumers of all ages to think about future needs.

Checking It OutMany of Lowe’s Accessible Home resources are organized in list form, such as the Slip & Fall Checklist. Th e Accessible Home Checklist is available in pdf form so consumers can print it out and review various areas of their homes.

Access both checklists and other resources at lowes.com/acces-siblehome. While the checklists can certainly be used by consumers, it’s probably better for them to team up with an accessibility profes-sional… for instance, with the seating & mobility provider or clini-cian who is already very familiar with the assistive technology that will be used inside the home! ●

8 mobilitymgmt.comnovember 2012 | mobilitymanagement

VMI Signs Deal to Convert Toyota Sienna

Research Results

Study Uncovers Data on SCI Among Military PersonnelA new study in the Journal of Bone and Joint Surgery reveals

information on spine, spinal cord and back injuries sustained by members of the U.S. military serving in Iraq and Afghanistan.

Of personnel evacuated as combat casualties, nearly 5.5 percent sustained spinal injuries: a total of 2,101 injuries out of 10,979 wounded. In 17 percent of cases where the spine was injured, the spinal cord was also injured.

Gunshots accounted for 15 percent of the total number of spinal injuries, but 53 percent of all gunshot wounds resulted in spinal cord injuries. Explosions caused 56 percent of spine injuries, while motor vehicle accidents caused 29 percent of those injuries.

Th e average age of the injured service member was 26.5 years, and spinal injuries were oft en accompanied by other injuries to the abdomen, chest, head and face.

Of the nearly 11,000 injured patients, 84 percent were hurt as a result of combat.

““In these current military confl icts, the latest technologies in body armor, helmets and other protective devices have helped save many soldiers’ lives,” says James A. Blair, M.D., an orthopedic surgery chief resident in the department of orthopedics and rehabilitation, Brooke Army Medical Center, Fort Sam Houston, Texas. “We also have access to advanced life-saving techniques in the fi eld and medical evacuation strategies that are keeping many more service members alive.

“But when a person survives an explosion or vehicle collision, there has still been a great deal of force on the body. Many of those survi-vors are coming to us with severe injuries to their spine and back. We needed to describe and characterize these injuries so recommenda-tions can be made on how to provide the most eff ective treatment and rehabilitation for our wounded warriors.”

A team of orthopedic surgeons reviewed eight years’ worth of medical records for the study. Th e American Academy of Orthopaedic Surgeons called the resulting analysis “an important fi rst step in helping orthopedic surgeons develop treatment plans for these service members, as well as for severely injured civilians who sustain similar disabling injuries.” ●

Vantage Mobility International (VMI) has signed an agreement to convert Toyota’s popular Sienna minivan into a wheelchair-

accessible vehicle.In a news announcement about the new partnership, VMI said

the conversion would include its patented Northstar in-fl oor ramp system. VMI also manufactures accessible conversions of the Honda Odyssey, Dodge Grand Caravan and Chrysler Town & Country minivan models.

“We’re pleased to have established a partnership with Toyota Motor Sales USA,” said VMI President/CEO Doug Eaton. “Toyota has earned a reputation for leading in customer loyalty, which is why our customers have wanted VMI to off er a Toyota Sienna for years. Th is agreement will give them the Toyota that they’ve dreamed about.”

Mark Oldenburg, Toyota’s manager of national fl eet marketing, mobility and strategic planning, said of the deal, “True to our brand promise, Toyota Mobility is focused on providing our customers with ‘More Options, Less Compromise.’  Th erefore, we are very excited about the opportunity we now have with VMI as another conversion solution for the Toyota Sienna. We’re also confi dent that our customers will be pleased once they see and experience the new Toyota Sienna with the VMI Northstar conversion.”

VMI, based in Phoenix, planned to begin accepting customer orders for the Sienna in October.

“VMI is pacing the build of Siennas at smaller quantities from previous product launches to ensure our commitment to quality,” said Eaton. “Initially it will be harder to get one, but you only get one chance to do a Toyota right.” ●

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mobilitymgmt.com 9 mobilitymanagement | november 2012

More than 500 occupational therapists visited Capitol Hill on Sept. 24 to talk to legislators about the issues aff ecting health care and occupational therapy in particular. The meetings were part of the American Occupational Therapy Association’s (AOTA) annual Hill Day. Among the talking points, according to an AOTA news announcement: Urging Congress to support the Medicare Home Health Flexibility Act (H.R. 2468) “to give occupational therapy equal footing among other services provided by home health agencies to allow Medicare benefi ciaries to receive the most appropriate skilled service to meet their needs”… Speaking of health services provided in the home: A new study by the Paraprofessional Healthcare Institute (PHI) found that 23 states do not have training requirements for personal care aides. PHI says 1.5 million personal care aides currently provide services to seniors and people with

disabilities, and the number of personal care aide jobs is projected to grow 70 percent by the year 2020. Additionally, PHI says, there is little consistency even among states that do require training for personal care

aides involved in publicly funded programs. In September, PHI presented its fi ndings at a Capitol Hill briefi ng co-sponsored by the U.S. Senate Special Committee on Aging and the U.S. Senate Health, Education and Labor and Pension committee. Sen. Herb Kohl (D-Wisc.) — the chair of the Senate Special Committee on Aging who has announced he is retiring after this term — said, “We are facing severe shortages of healthcare workers who are adequately trained and prepared to care for older and disabled Americans.” PHI reported that just a third of all states have training-hours requirements for personal care aides, while only 22 percent of states sponsor educational curri-cula. Eighteen percent of states require personal care aides to be certifi ed … Savaria Corp. has been chosen to install wheelchair lifts in nine stations throughout the East Railway Line’s high-speed train stations in China. Savaria, based in Laval, Quebec, reported it plans to install 27 Omega curved inclined platform lifts in the fall to provide “easy access for wheelchair passengers using rail to travel throughout the popular tourist destination of Hainan Island.” Savaria added the lifts “will be fi nished

briefl y…in stainless steel, off ering a modern look that complements the beautiful architecture of the award-winning railway system” … The American Academy of Neurology has released new guide-lines for treating chorea, the jerky, involuntary movements seen in patients with Huntington’s disease. The recommendations, published in the journal Neurology, include the medications riluzole, amantadine and nabilone, which have not traditionally been prescribed for Huntington’s patients. ●

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10 mobilitymgmt.comnovember 2012 | mobilitymanagement

Studies: Psoriasis Medication Eff ective as MS Treatment

Fastrack & Graham-Field Form Business Alliance

Dimethyl fumarate, also known as BG-12, has been found to be an eff ective treatment for multiple sclerosis (MS) according to

a pair of studies recently published by the New England Journal of Medicine.

Th e chemical has been commonly used to prevent mold in consumer products such as leather goods and furniture, and that use for dimethyl fumarate was banned in the European Union (EU) several years ago because of consumer complaints of itching, rashes and other allergic reactions, according to EUROPA, the EU’s offi cial Web site. Germany approved BG-12 as a psoriasis treatment in the 1990s.

Now, the Journal reports that trial participants who took BG-12

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Graham-Field Health Products and Fastrack Healthcare Systems have announced a strategic alliance that involves Graham-

Field’s product catalog and dealer price list being integrated into Fastrack’s inventory management and e-commerce modules.

Fastrack President Spencer Kay said in a news announcement that the integration would improve HME suppliers’ ordering and payment effi ciencies.

“Th e goal of this alliance is simple,” he said. “We want HME providers to focus on patient outcomes and let Fastrack soft ware take care of as many of their operational needs as possible.”

Th e newly integrated system debuted at Medtrade, which took place Oct. 15-18 in Atlanta.

Graham-Field CEO/President Ken Spett said of the new alli-ance, “Fastrack and Graham-Field have embarked on what will be a very successful collaboration in inventory management and online ordering. We want to help HME providers increase their effi -ciency and give them tools that can enhance their profi tability. HME providers can view Graham-Field’s inventory by warehouse and place orders directly from the Fastrack EDI Module without time-consuming phone calls or faxes.” ●

orally two or three times daily showed reduced numbers of MS relapses and brain lesions compared to those participants who had been on the placebo. Th e participants had been diagnosed with relapsing-remitting MS.

Patients receiving the doses of BG-12 also experienced a slowing of disease progression.

A Journal article about the studies said BG-12 “was shown to have anti-infl ammatory and cytoprotective (i.e., cell-protective) proper-ties in preclinical experiments and to result in signifi cant reductions in disease activity on magnetic resonance imaging (MRI) in a phase 2, placebo-controlled study involving patients with relapsing-remitting multiple sclerosis.”

Participants who received the BG-12 doses received 240 mg per dose. “Th e primary end point was the proportion of patients who had a relapse by two years,” the article said. “Other end points included the annualized relapse rate, the time to confi rmed progression of disability, and fi ndings on MRI.”

Of patients who received the BG-12 doses twice daily, 27 percent experienced MS relapses; 26 percent of patients who received three doses per day relapsed. Th e placebo group relapsed at a rate of 46 percent.

Reported side eff ects of the BG-12 included gastrointestinal issues such as nausea and upper abdominal pain, as well as decreased lymphocyte (a type of white blood cell) counts and elevated liver aminotransferase (i.e., enzyme) levels, the Journal article said. Elevated liver aminotransferase levels can be an indication of liver infl ammation or damage, according to MayoClinic.com. ●

mobilitymgmt.com 11 mobilitymanagement | november 2012

If you experienced adrenaline withdrawal following the close of the London Paralympic Games, there’s still another opportunity to be

inspired by Team USA.O.C. Tanner, the company that created commemorative rings for

this year’s American Olympians and Paralympians, also designed a hand-craft ed 14-karat gold ring given to winners of the O.C. Tanner Inspiration Award.

Wheelchair rugby player Joe Delagrave, wheelchair basketball player Natalie Schneider, and powerlift er Mary Stack each received an “Inspiration Ring” to give to a mentor “for encouraging and empow-ering their Paralympic journeys,” according to a news announcement from O.C. Tanner.

Winners were chosen by online voters, who read athletes’ nomina-tions. Th ose stories can be read by going to octanner.com/about-us/team-usa.

Stack, who received the most votes among the 13 Paralympic nominees, named her coach, Mary Hodge, as her inspiration.

“She’s helped me to see that I need to push myself to reach for the things I want in life, including my independence,” Stack wrote about her coach. “I believe a Paralympian is about being the best you can be, and because Mary believed in me, I believed in myself.”

Joe Delagrave nominated his wife, April. Joe was 19 and a college football player when his life changed: “Paralyzed in a boating acci-dent, I thought my athletic career was over, the chance of keeping my girlfriend was over, and I couldn’t see a future in a wheelchair. For three months I rehabbed in the hospital, and for three months that really awesome girlfriend never left my side.” As Joe took up wheelchair rugby and he and April moved across the country and away from their fami-lies so he could train, he says, “April never wavered in her support for me.”

Natalie Schneider nominated her father, Dennis Nelson. A star high school basket-ball player who learned the sport from her

U.S. Paralympians Name Th eir Inspirations

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dad, Schneider was diagnosed with osteosarcoma as a teen, but years later began playing wheelchair basketball. “Dad was thrilled that his girl was able to compete again,” Schneider said. “Aft er my fi rst year, he and my mom drove with me from Nebraska to Arizona so I could attend wheelchair basketball camp and Dad could learn more about the game. It was at that camp when he started telling people that I was going to be on the USA team, that it was only a matter of time.”

Peter Zeytoonjian, managing director of consumer products and licensing for the U.S. Olympic Committee, said of the rings, “Th e O.C. Tanner Inspiration Award recognizes the contributions and importance of the team behind the team. We congratulate Delagrave, Schneider and Stack and their mentors for their incredible sacrifi ce, dedication and exceptional teamwork.” ●

The Inspiration Ring features a victor’s laurel wreath and proclaims the ring’s owner a standout among mentors.

12 mobilitymgmt.comnovember 2012 | mobilitymanagement

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RESNA, the Rehabilitation Engineering & Assistive Technology Society of

North America, has announced its new board of directors. Th e members were appointed by new RESNA President Alex Mihailidis, Ph.D., P.Eng, and the new board held its fi rst offi cial meeting in late August.

Th e new board members are as follows: ● Paul J. Schwartz, MSIE, ATP, RET,

who has been appointed treasurer and will also chair the fi nance committee. Schwartz is a rehabilitation engineer and the assistive technology manager for the Stout Vocational Rehabilitation Institute at the University of Wisconsin-Stout.

● R. Lee Kirby, M.D., FRCPC, is a professor in the division of physical medicine and rehabilitation in the department of medicine at Dalhousie University in Halifax, Nova Scotia.

● Roger O. Smith, Ph.D., has been appointed to the executive committee as board member at large. Smith is a professor in the department of occupational science and technology, and director of the Rehabilitation Research Design and Disability Center (R2D2) at the University of Wisconsin-Milwaukee. Th ese three assistive technology experts join current board

members Patricia Bahr, MSE, ATP, RET; Jennifer Boger, P.Eng, MASc, BASc; Gerry Dickerson, CRTS, ATP; Heidi Horstmann Koester, Ph.D.; Lauren Rosen, PT, MPT, MSMS, ATP/SMS; Mark Schmeler, Ph.D., OTR/L, ATP; Richard Simpson, Ph.D., ATP; and Ed Steinfeld, D. Arch., AIA.

Ray Grott, ATP, RET, is currently RESNA’s president elect, and Jerry Weisman, MSME, ATP, RET, is the organization’s imme-diate past president. Jamie Arasz Prioli, ATP, is serving as RESNA’s treasurer.

New Assignments Handed OutMihailidis also made new committee assignments.

Glenn Hedman, PE, ATP, RET, has become chair of the Assistive Technology Standards Board. Hedman is a clinical associate professor

RESNA Announces New Board of Directors, Assignments

and coordinator of the Assistive Technology Institute at the Department of Disability and Human Development, College of Applied Health Sciences, University of Illinois-Chicago.

Nathan Moon, Ph.D., is now the chair of the government aff airs committee. Moon is associate director for research at the Center for Advanced Communications Policy at the Georgia Institute of Technology.

Alan Cantor, MA, will serve as chair of the special interest groups committees. Cantor is a disability and accommodations consultant based at the University of Toronto.

Additionally, Grott will head the bylaws committee and long-range planning committee. Weisman has become chair of the nominating committee due to his posi-tion as immediate past president.

“Starting from a small group of a few dedi-cated members, RESNA has grown into the premier organization of professionals and researchers with the common mission of maxi-mizing the health and well-being of people with disabilities through technology,” said Mihailidis. “I look forward to working with the board as we continue to move RESNA forward into the vastly growing international scene for assistive technology, and develop new strate-gies to continue to be leaders in this fi eld beyond our borders.”

Assistive Technology on the 2013 CalendarTh e next RESNA-hosted event is the AT Research Symposium, held in conjunction with the Assistive Technology Industry Association (ATIA) on Jan. 30 in Orlando, Fla. According to RESNA, “Th e topics of the symposium are cloud computing, mobile computing and apps. Th is all-day event will address critical research issues facing the AT research, manufacturing and vendor communities.”

Th e event is organized by Ben Satterfi eld, Ed.D., Georgia Tools for Life, Georgia Institute of Technology, ATIA Research Committee, and Rich Simpson, Ph.D., ATP, University of Pittsburgh, RESNA Research Committee. Go to resna.org for registration information, pricing and presenter information. RESNA’s 2013 conference takes place in Seattle, at the Hyatt Regency Bellevue, June 19-24. ●

Alex Mihailidis

Alan Cantor

Roger O. Smith

Paul J. Schwartz

Ray Grott

Glenn Hedman

R. Lee Kirby

Jerry Weisman

Nathan Moon

Info. Resources. Experts. Peers. Free!Whether you’re on your fi rst set of wheels or your fi ft h (or more!), you’ve got places to go and things to do once you get there.

Th eMobilityProject.com can help. Start with our resources, including event calendars, links to disability organizations, and lots of assistive technology products, complete with photos. Th en check out our news and feature stories, written with peer and expert input:

● Choosing a contractor for home accessibility modifi cations. ● Getting started in handcycling. ● Growing up with cerebral palsy. ● Finding the right accessible hotel room. ● Showcasing life aft er spinal cord injury. ● Navigating the unpredictable path of multiple sclerosis. ● Comparing strollers for kids with special needs. ● Funding options for veterans’ automotive vehicles. ● Much more!

It’s all waiting for you, 24/7.

Th e world is a big place. Take Th eMobilityProject.com along for the ride.

Th eMobilityProject.comPhoto courtesy Steam

boat Adaptive Recreational Sport

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Sign up for our FREE e-newsletter at TheMobilityProject.com! Click on “Follow” in the top navigation bar.

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14 mobilitymgmt.comnovember 2012 | mobilitymanagement

We’ve come a long way, baby. From the archetypal wooden leg of assailing pirates to the sci-fi wonder of the Six Million Dollar Man,

the art of prostheses has found a middle ground where functionality meets just the right mix of technological genius. Such are the wonders of today’s prosthetic appendages that athletes not only compete in elite sports such as triathlons and track and fi eld races, they set world records. Today’s prosthetics are lighter weight, more agile and more personal, with such features as tattoos.

But still the industry that addresses amputations remains somewhat of a mystery to many. For example, how prevalent is amputation in our more advanced culture? What are the clinical considerations for treating patients with amputations? And just where does mobility equipment fi t into the equation?

To fi nd the answers to these questions and more, Mobility Management went directly to the experts.

Amputations on the RiseBelieve it or not, amputations are actually more prevalent in today’s society than in years past. Th e reason? Chalk another one up to the obesity epidemic.

“Right now, in the U.S., about 50 percent of all amputations are due to vascular problems,” says Scott Cummings, past president of the American Academy of Orthotists and Prosthetists, a member of the Amputee Coalition’s scientifi c and medical advisory committee and a certifi ed prosthetist at Next Step O&P in Manchester, N.H. “And most of those are related to diabetes. We have an obesity epidemic in this country, and with it are projections to have an increase in diabetes-related amputations.”

Of course there are other reasons for amputations, Cummings says. Th e other two main categories are traumatic injury (think war-time inju-ries and car accidents) and congenital defects.

According to the Amputee Coalition, a Knoxville, Tenn.-based national nonprofi t organization that provides education, support and advocacy for limb loss, nearly 2 million people in the United States have limb loss. Vascular diseases such as diabetes and peripheral arterial disease account for 54 percent of those amputations, and trauma accounts for 45 percent.

Constructing the ProstheticTh e time between suture removal aft er surgery to remove a limb to the time of a prosthetic fi tting is generally three to six weeks. Th e fi rst pros-thesis or socket (the part that the residual limb fi ts into) is prefabricated and then fi tted to the patient.

“Th e new amputee can’t tolerate full weight bearing because he hasn’t healed up enough,” Cummings explains. “Th e concept with the custom fi tted is there’s a lot of swelling in the residual limb, and the residual limb isn’t going to be full weight bearing so that the fi t doesn’t have to be as perfect for the fi rst several weeks. And so, some doctors and prosthetists feel it’s more important to get them up right away and get them walking with something.”

Th at something is called an IPOP or immediate post-op prosthesis or preparatory prosthesis.

Aft er a few weeks — aft er the swelling has gone down, drains have been removed and the dressings are reduced — the prosthetist can get a better idea of the bony anatomy of the residual limb. At that point, the prosthe-tist will take a negative impression of the limb to make a custom socket, also called the defi nitive socket.

Th e size and shape of the residual limb will change dramatically over the fi rst 18 months aft er amputation because of muscle atrophy. Th erefore, the prosthetist will need to replace the socket to accommodate those changes.

“When somebody has a residual limb, there is an element of almost shaping, for lack of a better word, that has to happen,” explains Allison Gurwitz, OTR/L, ATP, at University of Maryland Medical System’s Kernan Orthopaedics and Rehabilitation in Baltimore, Md. “A lot of times there’s a lot of fi ne tuning and revisions to the prosthesis to make sure it’s fi tting properly.”

Th e user’s improvement with the use of the prosthesis could also mean that a better fi t is needed.

“Th ese people are getting more active, more weight bearing, more wearing time, and we expect the fi t will need to be better as they progress functionally,” he says. “So it’s important to maintain a really good fi t.”

A good indication that a new socket is needed is that the patient is “thumping” around on the prosthesis, Cummings says. In fact, the pros-

A Deeper Understanding of Amputations, Prosthetics and the Clinical Considerations of Wheelchair Fittings

positioning & prosthetics

By Elisha Bury

mobilitymgmt.com 15 mobilitymanagement | november 2012

thetist might do three sockets in the fi rst two years. Th en the fi ttings can be reduced to every three years and sometimes longer.

Oft entimes, a wheelchair is critical aft er surgery, especially for people with diabetes.

“If I have an amputation of one leg because of vascular disease or diabetes, the other leg is at what we consider a very high risk for a future amputation. I think like 50 percent of people have their other leg ampu-tated within fi ve years. So you’re trying to do everything and anything to preserve that other leg,” says Maria Lucas, PT, DPT, the clinical coor-dinator of the Amputee Program and coordinator for Professional Development and Education at MossRehab Hospital in Elkins Park, Pa. “I generally don’t recommend that the patients hop around or use a walker any more than they absolutely need to. Th ey should use their wheelchair for the majority of their mobility until they get their prosthesis in order to preserve the other limb.”

Of course, Lucas says, that wouldn’t apply to someone with a traumatic amputation because the other limb is not at risk.

Th e other thing to keep in mind is that oft entimes at the in-patient rehab level, the patient and team might not be ready to make a deter-mination of whether someone will need a wheelchair for the long term, Gurwitz says.

Mobility Equipment MattersAlthough a person with an amputation is generally given a manual wheel-chair initially, not all of these patients stay in one.

Generally if a prosthetist is meeting with an amputee, it’s because that person is itching to get out of a wheelchair.

“I’ll be evaluating a person with an amputation, and I’ll ask, ‘What are your goals?’ And they’re sitting there in the wheelchair, and they’ll tap on the handrails and say, ‘I want to get out of this wheelchair,’” Cummings says. “Th eir life before the amputation didn’t include the use of a wheel-chair, so they’re trying to get back to how they were before.”

Still there is a fair number of people who opt to use both a prosthesis and a wheelchair, especially when they are still building strength, balance, stability and endurance with the prosthesis.

Cummings says it’s not uncommon for an amputee to take a wheel-chair to a shopping mall to use between stores, but get up and walk the short distances between the aisles, for example.

“I will tell you that there’s a diff erence between the average below-the-knee amputee and the average above-the-knee amputee in the amount of energy expenditure to walk, resulting in the below-the-knee level having a better chance of being ambulatory than the above-the-knee amputees,” he says.

Th at has a lot to do with the fact that much more energy is needed to

use an above-the-knee prosthesis. For that reason, Cummings says it’s more common for above-the-knee amputees to decide to use a wheelchair.

Among patients with traumatic amputations or blast-related ampu-tations, that practice holds true. Dr. Heather L. Asthagiri, staff physi-cian in the Physical Medicine and Rehabilitation Services Department of Orthopaedics and Rehabilitation at Walter Reed National Military Medical Center in Bethesda, Md., says usually patients with bilateral lower-extremity and proximate bilateral lower-extremity amputations are more likely to use a wheelchair.

On the other end of the spectrum are elderly patients with comor-bidities. Lucas says these patients are far more likely to continue to use a wheelchair even aft er being fi tted with a prosthesis, which has a lot to do with energy expenditure.

“Th e vast majority of people with amputation are elderly patients with vascular disease and diabetes, so most of them are in their 60s or 70s. A lot of them will need the wheelchair for the times when they don’t have their prosthesis on. Th ey wake up in the middle of the night and have to go to the bathroom; they’d use the wheelchair,” Lucas says.

A wheelchair is also used by people who have cardiac problems and underlying renal disease and diabetes, she says.

“In reality, sometimes you’ll fi nd patients that they’ve always said they really want to walk, but when they get down to it, it’s much more diffi cult. Th ere’s defi nitely a signifi cant increase in energy demand to walk with a prosthesis vs. not having a prosthesis,” Lucas says. “If you lay that on top of them being medically sick and having cardiac problems, a lot of times, although they want to walk, they’re limited somewhat by their endurance.”

Gurwitz says the wheelchair can play an important role in energy conservation. Yes, a person might have the energy to use a prosthesis, but will that same person still have energy left to take a shower?

Gurwitz says there are a variety of considerations to determine whether someone will need a wheelchair long term. Th ese factors include:

● Age ● Comorbidities/medical history ● Cardiovascular tolerance ● Skin integrity and circulation (Is the patient at risk for wound develop-

ment with the prosthesis?)

Skin 101Believe it or not, pressure ulcers are

a problem even for people who use prostheses. Consider, for example, that the majority of people with amputations have vascular conditions or diabetes. These people also have very delicate skin that is prone to skin breakdown, explains Maria Lucas, PT, DPT, the clinical coordinator of the Amputee Program and coordinator for Professional Development and Education at MossRehab Hospital in Elkins Park, Pa. Whenever these patients develop a pressure ulcer or other skin irritation, they might

stop using the prosthesis and use their wheelchair instead.Fit of the prosthesis could be a cause for skin concern as well. “You can imagine if something’s not fi tting right, because of fric-

tion and rubbing, you can actually end up with pressure sores on that residual limb,” says Allison Gurwitz, OTR/L, ATP, at University of Maryland Medical System’s Kernan Orthopaedics and Rehabilitation in Baltimore, Md.

On the other hand, very active prosthetic users tend to dev elop minor skin irritations such as blisters from the pounding they do, Lucas says. “Most of them will probably not need a wheelchair because even if they do have a skin problem most of them can get around on crutches for a couple of days.” ●

We have an obesity epidemic in this country, and with it are projections to have an increase in diabetes-related amputations

— Scott Cummings

16 mobilitymgmt.comnovember 2012 | mobilitymanagement

There’s a signifi cant increase in energy demand to walk with a prosthesis vs. not having a prosthesis. If you lay that on top of them being medically sick and having cardiac problems, a lot of times, although they want to walk, they’re limited somewhat by their endurance

— Maria Lucas

● Upper-body strength ● Condition or strength of the intact leg ● Fitness level ● Body weight and body type.

For example, “if somebody is morbidly obese, they just may not have as easy an ability to be mobile in general,” Gurwitz explains.

Anatomy of the ChairWhen fi tting someone into a wheelchair, there are several important clin-ical considerations that are diff erent for people with amputations versus those with other mobility conditions.

For starters, center of gravity is a major issue, especially for bilateral lower-limb amputations.

“If you amputate someone’s leg, that moves the center of gravity higher, and that can be a problem in a wheelchair,” says Cummings, who frequently sees anti-tip bars installed to prevent tipping. “If you remove 20 percent of their body weight at their legs, now the center of gravity instead of being down near the hips is up closer to their chest wall. Th at makes them more tippy, especially going up a hill.”

Gurwitz likens the experience to sitting on an exercise ball. If you have too much weight behind the ball, the body will tip backward, and if you have too much weight on the front of the ball, the body will fall forward. She says to think of the wheels of the wheelchair as the ball. To give someone stability, you have to position them just right to prevent that tipping.

Th e usual method for adjusting center of gravity for amputees is to move the axle plates on the chair, Gurwitz says, and some wheelchairs even come with something called an amputee axle that extends the back

of the chair to put the wheels farther back.Gurwitz says that when she’s fi tting an amputee into a manual chair,

she looks mostly at the ultralightweight variety. Weight of the chair is defi nitely a consideration, but mostly she’s looking for the adjustability of that axle. Gurwitz says most of the ultralightweight chairs can be adjusted up and down as well as forward and backward, and that allows her to get the right adjustment for center of gravity.

In fact, when making adjustments to the chair, Gurwitz oft en considers the diff erence in seat height. She might, for example, make the back of the seat lower than the front of the seat so that the seat is sloped to give the user a better biomechanical advantage. For someone who has had a stroke and an amputation and might only have the use of one hand and one foot, she might also consider hemi height so that the seat is low enough for the person to push with the foot and propel with the hand.

Of course, there are drawbacks to these adjustments. For one, a low seat height could interfere with transferring.

“Th ings that are low are tougher to get up from than things that are higher,” Gurwitz says.

Also, the unfortunate side eff ect of moving the axle plates is that doing so can interfere with the patient’s ability to propel the chair.

“If I’m a bilateral and my center mass is too far posterior and I have to move the axle plates back to accommodate for that, what it really does is it makes propelling a little bit harder because now the actual handrims are more behind you. So you’re going to have to reach back for the arms to self-propel,” Lucas says. “Th en they also oft entimes have a lot of shoulder prob-lems because they’re diabetic and they’re very at risk for rotator cuff injuries.”

For power wheelchairs, adjustments have a lot to do with whether the

Amputee Coalition White Paper Addresses Limb Loss Prevention, CareIn September, the Amputee Coalition’s Limb

Loss Task Force released a white paper outlining new standards for limb loss preven-tion and care. The recommendations included developing demonstration projects and a media campaign to raise awareness.

The Task Force convened Feb. 9-12 in Washington, D.C., and included experts on amputee care and rehabilitation, limb loss

prevention, vascular medicine, diabetes education and management, healthcare policy and health system administration. Funding was provided by the Centers for Disease Control and Prevention and The Institute for Preventive Foot Health.

“While not all limb loss is preventable, the leading causes of amputa-

tion — complications from diabetes and peripheral arterial disease — can often be prevented through patient education, disease management and regular foot screenings,” said Dr. Terrence Sheehan, the Amputee Coalition’s medical director and chief medical offi cer of the Adventist Rehabilitation Hospital of Maryland, in a news release.

Sheehan noted that minority populations such as African Americans, Hispanic/Latino Americans and Native Americans are at higher risk for amputations related to diabetes and peripheral arterial disease.

Download the white paper at http://acoa.convio.net/site/DocServer/Limb_Loss_Task_Force_Paper_2012-Web.pdf?docID=221&AddInterest=1061. ●

Companion ProductThe Swing Away Amputee (HCPCS E1020) provides much-needed, adjust-able support for transferring. The product installs quickly on either the left or right side of wheelchair models ranging in tubing size from 7/8 to 1 inch. The support itself is constructed of soft entry foam with a fi rm base. The pad also features adduction to help center the residual limb. Find it at The Comfort Company, (800) 564-9248, comfortcompany.com. ●

Balancing Loss & Gain

positioning & prosthetics

mobilitymgmt.com 17 mobilitymanagement | november 2012

I have gotten power wheelchairs for people with amputations — it’s obviously a case-by-case basis — but it’s usually because there’s something that is preventing them from being a functional manual wheelchair user, even with that ultralightweight adjustable frame

–Allison Gurwitz

chair is rear-wheel, front-wheel or mid-wheel drive. And because the seating system is sliding along the base, “a couple of inches can make a tremendous diff erence to fi nd that stability,” Gurwitz says.

Power chairs are not oft en prescribed for people with amputations.“I have gotten power wheelchairs for people with amputations — it’s

obviously a case by case basis — but it’s usually because there’s something that is preventing them from being a functional manual wheelchair user, even with that ultralightweight adjustable frame,” Gurwitz explains.

She describes a patient who was 6 feet tall and weighed more than 400 pounds. Gurwitz says this woman didn’t have the stamina needed to propel a manual chair.

“What I actually did was I had her push a wheelchair around in a loop … and timed it. And I basically went to the insurance company and said, ‘Th at is not a functional amount of time to be able to go that amount of feet,’” Gurwitz says.

For patients with comorbidities such as stroke or cardiac issues or those with an upper-extremity amputation in addition to a lower extremity amputation, a power chair might be the right call.

A Positioning PlanTh e prosthesis can aff ect a wheelchair’s seating and positioning.

“We need to take into consideration whether they’re going to have a pros-thesis on or off ; that might aff ect the seat cushion decision,” Gurwitz says.

For example, one of the most important wheelchair additions, espe-cially for new amputees, is an elevated legrest to prevent the residual limb from hanging, especially if the patient will not be wearing the prosthesis in the chair.

“Fluid builds up in there, and it can cause swelling,” Cummings says. “So the legrest is actually elevated, and sometimes an extension between the seat and the elevated legrest is utilized to help hold that leg up hori-zontal with the fl oor.”

Lucas says it’s extremely important to install a limb support to prevent knee contractures. If the knee gets bent in a fl exed position, it will no longer fully straighten, she explains.

“Many of the legrests don’t accommodate for that because even if they lift the legrest all the way, their knee will still be partially bent when they rest it on there. So we recommend that they use a stump support… Th e problem we run into is that once the insurance pays for a stump support, they don’t want to pay for a regular footplate,” Lucas says. “So sometimes you just have to adjust — make a regular elevating legrest and make some modifi cations to it to support the limb with the knee in extension when they don’t have their prosthesis on.”

When considering the seating system, Lucas says the seating surface, as with most wheelchair users, plays an important role for amputees. “It’s not as critical as say someone who is spinal cord (injured) because obvi-ously the person with an amputation has no paralysis. So they’re moving around; they’re doing weight shift s all the time.”

However, there are some types of amputations that require a little more TLC, namely hip disarticulation amputations.

“Th at means that their limb is actually disarticulated at the level of their hip joint and all that remains is their pelvis on that side,” Lucas says. “What that really does is make their seating surface unequal, and so you’ll have to modify the seating surface in some way to make their pelvis sit level — that way you don’t develop any kind of scoliosis of their spine.”

At Walter Reed, Asthagiri says a rigid backrest is frequently ordered for wheelchairs, specifi cally because “posture is oft en aff ected with very prox-imal lower-extremity amputations.”

Another consideration that is somewhat unique among blast-related amputations is the need for multiple surgeries, which can aff ect seating needs.

“Our wounded warriors are oft en revisiting the surgical suite for heterotopic ossifi cation (development of bone in abnormal areas) removal, which if in the pelvic/sitting area, can change cushion needs,” Asthagiri says.

Also Gurwitz says a specialty back cushion can be helpful to aid with the adjustment of center of gravity.

“Maybe I’m going to mount it a little bit in front of the back handles as opposed to fl ush just so that their body weight is more in front to give them a little bit more center of gravity,” she explains. ●

Companion ProductThe Stump Support is all about the angle. Adjustable support between 45 and 90 degrees enables easier maneuverability through doorways and hallways. The support attaches to the wheelchair frame on the right or left side and features swivel locking handles to adjust position as needed. Contoured gel pads come in three sizes. Find the Stump Support at Gerber Chair Mates, (814) 269-9531, gerberchairmates.com. ●

Limb Loss by the NumbersThe following statistics on limb loss in the United States are provided by the Amputee Coalition, a Knoxville, Tenn.-based national nonprofi t organization that provides education, support and advo-cacy for limb loss.

● 2 million people have limb loss in the United States. ● 54 percent of limb loss is caused by vascular disease, including

diabetes and peripheral arterial disease. ● 45 percent of limb loss is caused by trauma. ● 185,000 amputations occur in the United States each year. ● $8.3 billion was the hospital costs associated with amputations

in 2009. ● Five years is the average length of time between amputation

and death for people with amputation due to vascular disease. ● 55 percent of people with diabetes with a lower-extremity

amputation will require an amputation of the second leg within two to three years. ●

18 mobilitymgmt.comnovember 2012 | mobilitymanagement

In its severest forms, spinal muscular atrophy (SMA) reduces the human lifespan to a few years or even less. Th e motor neuron

disease robs patients of muscle strength, making it diffi cult for them to breathe, swallow, cough. Children with the worst cases cannot sit up independently, and researchers, such as those at London’s Guy Hospital, have noted that some infants with SMA show reduced movement even in utero.

Yet parents of these children report that they are also expressive, sociable and bright — expansively so. And that can open a surpris-ingly hopeful window of opportunity for the clinicians and assistive technology providers who work with them.

SMA Defi ned by CategorySMA is commonly described by type: I, II, III and IV, though researchers also refer to SMA type zero in describing the most severe cases, in which symptoms are present before birth.

SMA types serve as shorthand that communicates what physical abilities patients might be expected to have.

Lauren Rosen, PT, MPT, MSMS, ATP/SMS, is the program coor-dinator for the Motion Analysis Center at St. Joseph’s Children’s Hospital of Tampa (Fla.).

“Children with type I usually have a short life expectancy — less than 2 years,” she says. “Th ey have respiratory and positioning issues throughout their lives and never meet any of their developmental milestones.”

Children with SMA type II, Rosen says, typically begin to show symptoms a little later — from 7 to 18 months of age — and can “learn to sit unassisted, but not to stand or walk independently. Although respiratory complications are a constant threat, children with type II SMA usually live to young adulthood, and many live longer. Once they start using wheelchairs, they have positioning issues and eventu-ally require power wheelchairs with power features.”

When muscle weakness manifests in older children and teens, “who learn to stand and walk, but lose the ability later in life, the disease may be labeled type III SMA, also known as mild SMA or Kugelberg-Welander disease,” Rosen says. “Although some with type

Spinal Muscular Atrophy Robs Clients of Their Strength, but Creative Thinking Can Make a Diff erence

Pediatric Series

By Laurie Watanabe

mobilitymgmt.com 19 mobilitymanagement | november 2012

III stop walking in adolescence, others walk well into their adult years. Th ese people usually slowly progress so they may use a standard power chair initially, but will eventually need a complex rehab chair with power features.”

Finally, there is type IV SMA, which has its onset “in the late teens adulthood, and people are able to walk during their adult years,” Rosen explains. “A lot of these people will start out with canes, then progress to a scooter or standard power. Some, depending on lifespan and progression, end up in complex rehab with power features.”

She adds, “Lifespan is usually normal in types III and IV.”

Type I: Immediate Intervention NeededFor children with SMA type I, assistive tech-nology intervention is typically needed from the very beginning, and in many diff erent forms.

Karen Patterson, PT, MS, PCS, has worked with children with SMA as part of the University of Wisconsin Doctor of Physical Th erapy Program. Patterson also works closely with Families of SMA (fsma.org), an organiza-tion devoted to funding research to treat and cure the disease.

While there is some variation of ability even within the diff erent types of SMA, children with type I, Patterson notes, “are never really able to sit by themselves. Th ese are the kids that have the bigger issues (with) respiration, swal-lowing, tolerance to being upright.”

With this group of children, Patterson explains, even the most basic positions need to be carefully considered: “We’ve got to take into account what is their respiratory status? What is their swallowing status? What position can they tolerate? Some of these kids cannot even tolerate up 30 degrees. It’s harder for them to breathe, and they can’t control their secretions. So they literally are being suctioned every few minutes.”

Rosen says children with type I “usually need medical strollers that have both tilt and recline to aid in breathing.”

Patterson concurs, saying type I patients may need a mobility system “that has the ability to go all the way fl at and even to a reverse Trendelenburg. Th ese kids don’t last in any sort of over-the-counter stroller for any length of time.”

For these infants and young children, she adds, having positioning options is critical. “Some of those kids end up with trachs. As they get older and they do end up with a trach, they tolerate upright better, but obviously they need

to be able to carry the equipment. So from a positioning stand-point, you’re looking at something that can handle that.”

Deciding whether or not to choose a tracheostomy can be immensely personal and diffi cult for a family. Patterson notes, “We talk about this on our medical advisory board: not pushing parents to make that choice. Th is is certainly a diagnosis where parents may not choose to have their child get a tracheostomy and may let nature take its course, so to speak.”

But clinicians and providers who recommend and build the seating & mobility system should still have a plan for accommo-dating a possible ventilator, as well as other equipment.

20 mobilitymgmt.comnovember 2012 | mobilitymanagement

Pediatric Series

“Even early on, and even on those kids that are younger and their tolerance to upright is so-so, they’re still going to have a lot of equip-ment,” Patterson says. “Th ey’re still going to have a cough-assist machine that they travel with. Th ey’re going to have an IV pole. Th ey’re going to have those extra things that we have to account for. You have to have something that has a lot of options to it.”

Patterson also notes that children with type I need head posi-tioning support that allows for a lot of fi ne-tuning. “You really need to think about head supports that have a lot of adjustability,” she says. “Th ey have no head support whatsoever, and it aff ects their swal-lowing, it aff ects their breathing, the position of their head. So being able to tweak it just a little bit can make or break whether a kid can tolerate more of an upright position.”

Type II: Adjustability Is KeySince children with SMA type II can sit unassisted at some point but do not stand or walk, a seating system with adjustability is important.

Rosen notes that while kids with SMA could benefi t from molded trunk supports, “in many cases, they don’t like the feel of those systems. So they can end up with signifi cant scoliosis, which makes sitting and breathing more diffi cult.”

“Th ese are kids that are absolutely at extremely high risk for scoli-

osis,” Patterson says. “Th ey’re at high risk for hip pathology. Th e seating system is very important and something that has to contin-ually change with the kid a little bit. Many of these kids end up in TLSOs (thoracolumbosacral orthoses)."

To achieve that changeability, Patterson suggests laterals that can be adjusted. “Th ese kids don’t have enough strength ever to really do a pressure relief,” she says, “so typically, you have to get tilt and recline on the chairs.” She says children with type II can usually control their secretions and don’t need respiratory assistance when they’re upright and in their wheelchairs, though they might still need a cough-assist machine on occasion and oft en use biPAP to help with respiration at night. Recline, Patterson adds, can make some daily activities a little easier for caregivers, while tilt for pressure relief is crucial.

Also, Patterson says, the usual pediatric growth adjustability is important to build in. “I can’t point to any literature that supports it,” she says, “but these kids actually grow fairly quick. Most of the time, they grow long…especially the type Is.”

Children with type II can also benefi t from standing, Patterson says, to experience some weight-bearing (kids with type I can also benefi t, she adds, though they may prefer standing short of vertical).

Rosen notes, “People with type II frequently go from nothing to a power wheelchair given their age and the likely progression.

Keeping Your Options Open

mobilitymgmt.com 21 mobilitymanagement | november 2012

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Miracle Boy: Growing Up in an American RevolutionWhen NPR commentator, author,

husband and father Ben Mattlin was 3 years old, he fell from his new wheelchair as his father pushed it down a steep ramp. Because of his amyotonia — as spinal muscular atrophy was known when he was a young child — Mattlin, now 50, likened himself to a rag doll, unable to keep from rolling down the ramp. Mattlin later saw his mother lecture his shaken father about using the wheel-chair’s seatbelt. His mother then turned to her young son, urging him to also remind caregivers to fasten that belt.

“I try to take her admonitions as seriously as I can,” Mattlin writes. “Speak up. Don’t be shy… I hear these phrases a lot. Light a candle instead of cursing the darkness.” Mattlin understood the message, but also realized his wonderful new wheelchair “brings a host of unfore-seen risks and burdens. Everything is double-edged! … I’m not yet four, but I might as well be 40.”

Published in August, Mattlin’s book, Miracle Boy Grows Up: How the Disability Rights Revolution Saved My Sanity is more than

Mattlin’s personal story. It’s also a history of how accessibility rights came of age in America. Mattlin was growing up at the same time that his country was working to comply — often not very enthusiastically — with accessibility legislation such as the Rehabilitation Act of 1973. Those growing pains, along with Mattlin’s own experiences, changed his perceptions of the world, of people with disabilities, and of himself.

In his book, Mattlin dismisses his lifelong resilience as simple neces-sity, and shares anecdotes and experiences that fall decidedly on the opposite side of sainthood. As a child, Mattlin fantasized about being a superhero, but he works hard in his memoir to prove he is just an ordinary guy who, as the saying goes, has lived in interesting times. Calling on a sharp wit and a gift for language — he discovered early on how powerful his words could be — Mattlin declares in the book’s introduction that he is simply telling the truth. If we happen to be inspired by his story, he adds with a presumed wink, that’s our problem.

It’s a problem I suff ered repeatedly while reading Miracle Boy.

— Laurie Watanabe ●

Ben Mattlin

22 mobilitymgmt.comnovember 2012 | mobilitymanagement

Pediatric Series

House Passes Pediatric Research Network Bill A bill that could impact eventual treatments for rare diseases and

conditions found in children, including spinal muscular atrophy, has passed in the U.S. House of Representatives.

H.R. 6163 calls for amending title IV of the Public Health Service Act to provide for a National Pediatric Research Network focusing on pediatric rare diseases and conditions.

The Network would be empowered to award grants and other forms of funding to public or private non-profi t organiza-tions that conduct "basic, clinical, behav-ioral or translational research to meet unmet needs for pediatric research and

training researchers in pediatric research techniques," the bill says.Entities receiving such funding would “focus primarily on pediatric

rare diseases or conditions, including any such diseases or condi-tions that are genetic disorders, such as spinal muscular atrophy and Duchenne muscular dystrophy, or are related to birth defects, such as Down syndrome and Fragile X,” the bill adds. Researchers would be required to conduct or coordinate clinical trials regarding disease prevention, diagnosis or treatment and “rapidly and effi ciently disseminate scientifi c fi ndings resulting from such trials.”

FightSMA (fi ghtsma.org), an organization devoted to fi nding a treatment and cure for the illness, called the bill’s Sept. 19 passage “an unprecedented step forward for the advancement of clinical research on rare pediatric disorders.”

In a statement about the bill’s passage, the organization added, “Legislation directly impacting the fi ght against spinal muscular atrophy has never before experienced this level of success in Congress, and many thanks must be given to the bill’s lead spon-sors, Reps. Cathy McMorris Rodgers (R-Wash.), Lois Capps (D-Calif.) and Diana DeGette (D-Colo.). Their leadership, along with the strong support of Majority Leader Eric Cantor (R-Va.), led to the bill passing through the Energy and Commerce Committee and the full House with overwhelming bipartisan support.”

The focus now turns to a companion bill in the Senate, S. 3461, introduced in July by Sen. Sherrod Brown (D-Ohio). The bill, which had seven co-sponsors at press time, is currently in committee. The latest senators to sign on — Roy Blunt (R-Mo.) and Chuck Grassley (R-Iowa) — added their support the day H.R. 6163 passed in the House. ●

Types III & IV: Changing Throughout a LifetimeChildren with type III SMA can stand and walk, typically into their teens or even adulthood, when lifetimes of progressing muscle weak-ness take their toll, “and distances tend to shorten,” Patterson says about walking ability.

Spine issues such as scoliosis tend to be less of a problem in type III patients, Patterson adds, but they do typically use a variety of mobility equipment throughout their lives.

“Depending on their age and type of SMA, some people, especially type III or IV, may initially use an ultralightweight wheelchair,” Rosen says. “Older individuals with type IV may also use scooters for quite some time.”

“Kids that are type IIIs that can still propel need something ultra, ultralightweight,” Patterson points out. “Typically, we see even type IIIs in adulthood go towards a power chair.”

Positioning for Power Chair Operation SuccessOne of the greatest challenges in working with children with SMA — especially those with types I or II — is fi guring out how to support their quest for independent mobility.

Citing the “variability” within the diff erent types of SMA, Patterson says, “Th ere certainly are kids in type I that are strong enough that they tolerate being upright, and they get to the point of being able to drive a chair.” But they need high-tech options to do so, she adds, such as eye-gaze systems, since SMA does not usually impact the eyes. Patterson also says “a little bit of minute pressure of the distal fi ngers is possible, because they tend to stay stronger distally.”

In that case, the clinician or provider will still have to experiment to determine the most eff ective position for the child’s hand.

“Th ere’s even a variability of hand position, like maybe with their hand in a neutral position, with thumb up,” Patterson says. “Maybe from there, they can fl ex their DIP (distal interphalangeal) joint. But if they’re against gravity, they can’t fl ex it. It’s really that minute. Gravity is their enemy, and if you change the position of their body, you change the pull of gravity on them. You have to take that into account.”

Would bringing drive controls closer to midline be helpful?“It’s interesting that a lot of kids with type II do move to midline,

but a lot of kids with type 1 will stay laterally,” Patterson says of where they prefer drive controls to be mounted. “Probably because there is (no strength) proximally at all with type I. So the wrist has to be extremely supported, but they still can stay (with the joystick) laterally.”

Due to extreme muscle weakness, other types of driving tech-nology, such as fi ber-optic switches, may be the best solution for these kids. Th e good news: Intellectually, they’re up to the task.

“Th ese kids are not cognitively aff ected,” Patterson says. “Th ey’re smart enough to do it.

“Th ere’s a very famous article that I use all the time (see sidebar) of a 20-month-old with SMA learning how to drive profi ciently. Th ese kids can learn very early. Th is is the population you start (on power mobility) really early, because cognitively, they’re going to get it.”

Frequently, due to their weakness in the shoulders, they need at least power tilt and hopefully power seat elevation. As they get older, adding the other power features is usually necessary as well.”

Patterson adds that parents of kids with type II SMA typically like power seat elevation. “Th ey’re going to be in power (mobility) for so long,” she explains of these children, “so getting at the diff erent levels of their peers, especially when they get to middle school or late elementary when they’re maybe not standing quite as much” is a real benefi t.

Keeping Your Options Open

mobilitymgmt.com 23 mobilitymanagement | november 2012

PT Journal: Power Chair Success for 20-Month-Old The March 2003 issue of Physical Therapy, Journal of the American

Physical Therapy Association, includes an article called “Use of Power Mobility for a Young Child with Spinal Muscular Atrophy.” Authors Maria A. Jones, Irene R. McEwen and Laura Hansen detailed their work with Molly, a 20-month-old with type II spinal muscular atrophy. Within six weeks of being introduced to her power chair, Molly was operating it independently. To read or download the abstract, go to ptjournal.apta.org/content/83/3/253. ●

Th at includes giving kids control over power seating functions, such as tilting to perform weight shift s.

“Absolutely,” Patterson says, emphasizing their cognitive abilities. “And they’ve got complete sensation as well.”

Keeping Your Options OpenWhile a seating & mobility system’s fl exibility and adjustability is always important for complex rehab technology clients, that need is especially acute for kids with SMA. When working with these clients, having a wide range of options is critical.

“I would say it’s one of the biggest issues that I run into,” Patterson says. “I’m in a neuromuscular disease clinic, and we see a fair number of kids from all over the country. It’s the lack of options that is the most frustrating.

“A chair gets selected for a kid, and it may be appropriate. But as the kid changes in a matter of a few years, we can’t do this or that, or we’re going to have to submit all this paperwork to get this change made.”

And in addition to embracing options such as head and arm posi-tioning, ATPs should also keep in mind how typically bright and social kids with SMA tend to be.

“I talk to a lot of families, and parents are always trying to fi gure out how to tap into that,” Patterson says. “Especially with type I, an

eye-gaze system is almost too slow for these kids. Th ey get too frus-trated; they’re 10 steps ahead. Th e iPad has opened up a huge world for these kids, because if they can position their arms correctly, they have enough motion that they can (use) an iPad. I’ve had the UW engi-neering students take this on as a project: how to mount devices like that on their chairs even if the kid is side-lying or in recline.”

Giving a child with SMA every opportunity to be independent requires work, but Patterson says the eff ort is well worth it: “Th ese kids are endless in what they can learn.” ●

24 mobilitymgmt.comnovember 2012 | mobilitymanagement

After more than 30 years in the complex seating & mobility business, National Seating & Mobility’s (NSM) Shelly Torres-West is retiring at the end of the year. Here, she looks back and also forward. — Ed.

q: What made you decide to retire in December?

a: I came to this decision because of all the funding issues. There’s so

much stress now in this fi eld. We never had these levels of stress when we could make our own stuff and be more creative instead of having to buy things. We would just create our own stuff . But then we had stop doing that because of

liabilities, which makes sense. I won’t miss the paperwork at all, and now there’s so much

stress with trying to get your paperwork in on time. No matter what your vision is, the bottom line is always the dollar in this business. That’s just the way it is. It’s got to be that way to run a business, and I understand that. If I were a manager or owner, I’d probably give the shop away; I don’t think I’d be too successful!

q: Has the funding environment hindered your ability to be as creative as an ATP?

a: Somewhat, because there are things that are really expen-sive. There are manufacturers that will make you almost

anything you want, but it costs. It costs in research, it costs to tool up for it, it costs to create the parts, and it costs to pay their engi-neers. It comes at a price.

It’s hard to get not only the consumers to understand why this stuff is so expensive, but also the funding sources, for them to understand the research and development that goes into it.

If it were up to me, every person on Capitol Hill and every person in every state capital in the country would have a handi-capped child at home for one week with no equipment to help them. Then they might get the picture.

q: Has the percentage of time that you spend doing docu-mentation and paperwork drastically increased in the

30 years you’ve been in this fi eld?

a: I have to say yes, it’s changed, but I don’t know that I can put a fi nger on a number. It’s been so gradual. I was trying

to think back to the days before the laptops and the iPads, when I used to go to IHOP and sit there and drink coff ee and do paper-work for a couple of hours.

There are people that say, “Don’t think of the funding, think of the client fi rst. Think about everything you want for that client, and then fi ght for it.” Idealistically, that’s what I would like. That’s what we all would like. We all want to give our clients whatever they need to help their situation. Unfortunately, too many other people have given clients everything they don’t need. And so it’s kind of ruined it for the rest of us.

q: You’ve worked with Sara Moore, ATP, also with NSM, for a long time, even before you two started your

own seating & mobility company called Adapted Systems Unlimited. What kept you going?

a: We loved what we were doing. We were helping people. We could try things people hadn’t tried before. We would brain-

storm and come up with some really fun stuff . To be able to help people, it was something that we both loved to do. It wasn’t so much a business as it was a passion.

q: So where do you go from here? How will you be spending your retirement?

a: Some nights and weekends, I’ll be singing. More and more singing jobs are coming my way, so it’s awesome.

I’ve applied for my Social Security, and I’m going to drive a school bus. I’ll be done at 8:30 in the morning, and I don’t have to be back to drive again till 2:30 in the afternoon. During that time, I have another business that I do called Legal Shield. It’s an exciting business; it also helps people.

I also want to start The Helmet Project, where every NSM offi ce would have a fi t kit. You get a helmet for a kid, but the helmet doesn’t fi t because you didn’t have a fi t kit. Then you have to ship it back and get the right size, and then there goes your profi t.

It’s hard to get the funding for anything extra, so I want to start a project where eventually I’ll be able to fund the helmets. Whatever Medicaid won’t pay for, my group will make up the diff erence so the kid will actually get the helmet they need without the headache. There’s hardly any profi t in a helmet, but it’s something kids desperately need. And a lot of vendors either get it and eat the cost, or they won’t get it. Because I’ve had so many issues with the helmet situation, I see a need. I think a lot of problems could be solved by having a fi t kit.

q: So, you’ll still be working with kids, but as a school bus driver. And what happens the fi rst time you see a child

in a wheelchair and you notice his seating or positioning isn’t quite right?

a: I’m gonna work on it! (Laughs.) You have to be careful in a situation like that. I would probably send a note home to the

parents and tell them to contact their vendor. ●

It’s Been a Real Journey!

By Shelly Torres-West, ATP, National Seating & Mobility

Shelly Torres-West, ATP, is with

NSM’s Arlington, Texas, offi ce.

An accomplished singer, she’s

shown here at NSM’s 2005

symposium.

another opinion

mobilitymgmt.com 25 mobilitymanagement | november 2012

One of the most time-consuming parts of an evaluation or fi tting of a power wheelchair can be the custom

programming required to meet the consumer’s individual needs. Programming can be one of the most intimidating parts of a fi tting if you are not comfortable with programming the power wheelchair’s electronics.

Th ere are many diff erent parameters to program, from driving parameters to special features that allow a consumer independent access to the electronics. Th e trick to making this easier is to under-stand how the consumer wants and expects the power wheelchair to drive or handle. Th is can only be understood through programming the power base, then having the consumer control it, then perhaps programming it some more.

Driving ParametersTh ere are so many diff erent parameters available to fi ne-tune how a power wheelchair drives and responds to the client’s input commands. Th e fi rst thing you need to keep in mind is how and where the consumer has used a power wheelchair in the past and what sorts of electronics are needed to drive his or her power wheel-chair. Answering these questions can allow you to have a better understanding of exactly what the consumer’s expectations of the wheelchair are going to be and how the wheelchair needs to be programmed to respond and drive in diff erent environments.

When programming driving parameters, it is important to consider whether the input device is proportional or non-propor-tional. If it is a proportional controller, then the consumer can make fi ne adjustments to speeds and the way the power wheelchair handles by adjusting how far the joystick is defl ected in a certain direc-tion. Th is type of drive input device typically requires less up-front programming, since the consumer has the ability to adjust the respon-siveness of the electronics through the amount of joystick defl ection provided, as well as adjust the speed pot knob to make changes to the speed the wheelchair will travel.

A few of the parameters that are extremely important to consider are all the speeds, accelerations and decelerations for all directions of control. All of these parameters need to be adjusted specifi cally to how the consumer wants the wheelchair to react. Th ey may even need to be diff erent in each profi le the consumer may use: for instance, an indoor profi le with slower speeds and an outdoor profi le with faster, more aggressive speeds. Keep in mind that there is a misconception from time to time that a wheelchair should drive perfectly right out of the box. It is our job as equipment providers and therapists to adjust a wheelchair to the consumer’s individual needs. We should always expect to make some changes to the programming for every power wheelchair fi tting we take part in. If we don’t make changes to the programming, then the outcome for that wheelchair will be less than favorable.

A good example of why this program-ming is necessary for every fi tting is an equipment provider or therapist who may work with two diff erent individuals with cerebral palsy. One individual may be able to release the joystick quickly when stopping the power wheelchair, while the second may release the joystick more slowly. Th e individual who can release the joystick quickly to stop can have the wheelchair programmed so the wheelchair comes to a more gradual stop. Th e individual with a slower reac-tion time needs the deceleration turned up higher in order to stop within a safe distance. Every person is unique, and therefore every wheelchair will be programmed diff erently.

Proportional Control ConsiderationsAs an equipment provider or therapist, our goal should always be to keep an individual driving with a proportional control for as long as possible, as proportional controls provide the consumer with greater control over the power wheelchair. Th e team should explore every proportional control programming feature a manufacturer off ers before they change the input method to a non-proportional input device. To do this, the team must be very familiar with the propor-tional programming features off ered.

A few of the features to be explored by the team may include allowing changes to increase the size of the neutral zone of a joystick, dampening or suppressing tremors to the joystick, reassigning each direction the defl ection of a joystick represents, or decreasing the throw of a joystick required to reach maximum speed. Each of these features has a place and can benefi t a multitude of individuals who drive power wheelchairs. We need to ensure that we are familiar with each of these parameters and how they change the way in which the joystick input device controls the power wheelchair.

Non-Proportional Control ConsiderationsWhen it comes to non-proportional input devices, the programming for these devices will need to be set up very diff erently from a propor-tional input device. A non-proportional device is on or off , and it does not off er much speed control. Th erefore, this type of input device does not off er the fi ne adjustment that can be performed with a propor-tional input device. People who use non-proportional input devices typically have less control with their bodies and therefore fewer access sites on their bodies.

Drive Controls & Programming a Power Chair

Jay Doherty, OTR, ATP/SMS, is

the clinical education manager

for Pride Mobility Products Corp.

Jay can be reached via e-mail at

jdoherty@pridemobility.com or

by calling (800) 800-8586.

clinically speaking

Continued on page 26

By Jay Doherty, Pride Mobility Products

26 mobilitymgmt.comnovember 2012 | mobilitymanagement

When setting up programming for a non-proportional device, we should consider off ering a greater number of profi les for diff erent driving situations. A typical profi le layout for a non-proportional input device may appear as follows: • Profi le 1: Indoor driving and driving in tighter spaces• Profi le 2: Driving in hallways and larger spaces• Profi le 3: Driving outdoors, in very large open spaces• Profi le 4: Auxiliary functions (e.g., environmental controls,

computer access, or access through the input device for a commu-nication device)

• Profi le 5: Power seat functionsOnce the decision has been made about how many profi les the

consumer would like, you can proceed with the setup of the driving parameters.

Programming of how the power wheelchair handles with a non-proportional input device can signifi cantly infl uence how much a person uses and likes the power wheelchair. We need to look very closely at all the environments that the person drives within and do a good amount of fi ne-tuning with all driving parameters. Every driving parameter should be adjusted or at least looked at while considering how it will infl uence the wheelchair’s maneuverability in

clinically speaking

each environment. Unlike a proportional input device, a non-proportional input

device will require a signifi cant amount of time spent programming each drive profi le for the individual’s comfort level.

Beyond the drive parameters, there are many options to consider with each non-proportional input device. You may need to program multiple functions to be performed with one switch (e.g., on/off , mode changes, and emergency stop). It may be necessary to program a specifi c way for a head array to control the power seat functions, or the individual pressures needed for a sip-and-puff system. Setting up the programming for a non-proportional input device can take a great deal of time and investment by everyone on the team, so a big commitment will be necessary.

Keep in mind you may need multiple appointments in order to maxi-mize the individual’s independence with the input method. Multiple appointments does not mean the team is not good at programming, but rather that the team is thorough and making sure the consumer is getting the maximum independence out of the power wheelchair.

We need to remember that, in the end, the time we put in at the beginning stages of a fi tting provides a better outcome and a greater level of independence for the consumer. And isn’t that why we all joined this industry in the fi rst place? ●

Statement of Ownership, Management and Circulation(Required by 39 U.S.C. 3685, United States Postal Service)

1. Title of Publication: Mobility Management2. Publication No. 1558-67313. Filing Date: 09/28/124. Frequency of Issue: Monthly5. Number of Issues Published Annually: 126. Annual Subscription Price: US $119, International $1897. Complete Mailing Address of Known Office of Publication: 9201 Oakdale Ave., Ste. 101, Chatsworth, CA 913118. Complete Mailing Address of the Headquarters of General Business Offices of the Publisher: Same as above.9. Full Name and Complete Mailing Address of Publisher, Editor, and Managing Editor: Karen Cavallo, Group Publisher, 9201 Oakdale Ave., Ste. 101, Chatsworth, CA 91311 Laurie Watanabe, Editor, 9201 Oakdale Ave., Ste. 101, Chatsworth, CA 91311 10. Owner (s): Stevens Publishing Acquisition, Corp. (SPAC), 9201 Oakdale Ave, Ste. 101, Chatsworth, CA 91311. Listing of shareholders in SPAC.11. Known Bondholders, Mortgagees, and Other Security Holders Owning or Holding 1 Percent or more of the Total Amount of Bonds, Mortgages or Other Securities: Nautic Partners V, L.P., 50 Kennedy Plaza, 12th Flr., Providence, RI 02903 Kennedy Plaza Partners III, LLC, 50 Kennedy Plaza, 12th Flr., Providence, RI 02903 Alta Communications 1X, L.P., 1X-B, L.P., Assoc., LLC, 28 State St., Ste. 1801, Boston, MA 0210912. The tax status has not changed during the preceding 12 months.13. Publication Title: Mobility Management14. Issue date for Circulation Data Below: September 201215. Extent & Nature of Circulation: Average No. Copies Each Month No. Copies of Single Issue During Preceding 12 Months Published Nearest to Filing Date a. Total Number of Copies (Net Press Run) 11,191 8,634 b. Legitimate Paid/and or Requested Distribution 1. Outside County Paid/Requested Mail Subscriptions Stated 7,940 6,368 on PS Form 3541 2. In-County Paid/Requested Mail Subscriptions Stated 0 0 on PS Form 3541 3. Sales Through Dealers and Carriers, Street Vendors, Counter 0 0 Sales, and Other Paid or Requested Distribution Outside USPS® 4. Requested Copies Distributed by Other MailClasses Through 0 0 the USPS c. Total Paid and/or Requested Circulation 7,940 6,368 d. Nonrequested Distribution 1. Outside County Nonrequested Copies Stated on PS Form 3541 2,693 2,055 2. In-County Nonrequested Copies Distribution Stated on 0 0 PS Form 3541 3. Nonrequested Copies Distribution Through the USPS by Other 0 0 Classes of Mail 4. Nonrequested Copies Distributed Outside the Mail 391 50 e. Total Nonrequested Distribution 3,084 2,105 f. Total Distribution 11,024 8,473 g. Copies not Distributed 167 161 h. Total 11,191 8,634 i. Percent paid and/or Requested Circulation 72.02% 75.16%16. Total Circulation includes elections copies. Report circulation on PS Form 3526X worksheet.17. Publication of Statement of Ownership for a Requester Publication is required and will be printed in the November 2012 issue of this publication.18. I certify that all information furnished on this form is true and complete: Jenny Hernandez-Asandas, Director, Print and Online ProductionIf you are using PS Form 3526R and claiming electronic copies complete below: a. Requested and Paid Electronic Copies 1,624 3,697 b. Total Requested and Paid Print Copies (Line 15C) + Paid Electronic Copies 9,564 10,065 c. Total Requested Copy Distribution (Line 15F) + Paid Electronic Copies 12,648 12,170 d. Percent Paid and/or Requested Circulation (Both Print & Electronic Copies) 75.62% 82.70% I Certify that 50% of all my distributed copies (Electronic & Print) are legitimate requests.

X

X

Continued from page 25

Drive Controls & Programming a Power Chair

mobilitymgmt.com 27 mobilitymanagement | november 2012

Versair BackDesigned to provide comfort and support for optimal positioning and function when standard sling upholstery is not enough, the Versair features alternating tension straps. Easily adjustable to meet individual needs, the straps can be made taut in the lower back for optimal sacral support, or relaxed in the upper back to accommodate posterior pelvic tilt thoracic kyphosis. The Versair back can stay on the chair even when the chair is folded for transport.

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

Walk StarOttobock has created this posterior walker for active kids on the go. The folding gait trainer comes in fi ve sizes and three colors, and fi ts children as young as 2 years old. Thanks to telescoping frame tubes, Walk Star grows with kids, while a wide variety of accessories makes it possible to customize the Walk Star according to each child’s clinical needs. Swivel front wheels allow for quick turns, and locked front wheels make the system more stable.

Ottobock (800) 328-4058ottobockus.com

TubBuddy with TiltAn ergonomically designed bathing transfer system, this TubBuddy incorporates tilt in space to relieve pressure during bathing. It features a 350-lb. weight capacity, a tapered cushion with tailbone recess, removable and lockable foldaway arms and removable/swing-away footrests. TubBuddy has a full aluminum frame with stainless-steel hardware, with tool-less assembly and 5" locking casters.

ShowerBuddy LLC (877) 769-2833myshowerbuddy.com

JAY FusionCreated to be comfortable, stable and supportive, the JAY Fusion adjust-able skin-protection seat cushion features JAY Flow fl uid or ROHO Dry Floatation air inserts to combine the J3’s stability with the J2’s pressure management capabilities. Includes a fi rm, structural foam base with a soft foam top layer for both stability and a comfortable sitting surface. The Pelvic Loading Area incorporates a rear wall and femoral transition shelf to prevent fl uid migration and pro-vide posterior pelvic and trochanteric support.

Sunrise Medical (800) 333-4000sunrisemedical.com

product revueKanga TS Folding ChairThis pediatric chair has a built-in growth frame that confi gures to 10", 12" and 14" widths (with the adult model adjusting to 16", 18" and 20"). The Kanga TS features tilt in space, adjustable seat depth and seat back angle, curb-assist levers, 20" rear quick-release semi-pneu-matic wheels, height- and angle-adjustable armrests, and push handles. The chair folds for easier transport and is bus-transit compatible.

Wenzelite Re/hab (877) 224-0946drivemedical.com

28 mobilitymgmt.comnovember 2012 | mobilitymanagement

ChariotThis patent-pending lift on wheels enables a small or mid-sized car to transport a scooter or power chair weighing up to 350 lbs. With its own independent suspension, Chariot puts minimal weight on the rear of the car. Compatible with a Class I or II hitch, the Char-iot has two wheels that swivel so they follow the car precisely without danger of jackknifi ng.

Bruno Independent Living Aids(866) 882-4990bruno.com

Gatehouse Ramp SystemThis system was created to be aff ordable and customizable with-out sacrifi cing style. Combining the aesthetics of a custom-built wood ramp with the easy instal-lation of a modular aluminum ramp, Gatehouse off erings include straight, right, left and U-turn pieces to fi t varied needs.

Lowe’s(800) GO-LOWESlowes.com/ramps

Nosing RampsDesigned to eliminate the daily “bumps” at home, these solid rub-ber ramps are extremely durable and slip resistant. They require little to no installation and can be easily modifi ed to fi t around mold-ings and in tight spaces, or can be left unsecured for easy portability to other locations needing a more convenient entryway.

Diestco Mfg. Corp.(800) 795-2392diestco.com

EleV8 RampThanks to its design, the EleV8 answers a full range of threshold rises and requires minimal instal-lation. The line includes eight dif-ferent sizes — primarily for doors that swing away from the house, but for other entrances as well. In two widths (32" and 36"); features limited lifetime warranty.

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

Pathway SystemThe integrated corner pockets of the Pathway enable positioning of the ramp fl ush against any surface. A freestanding angled platform conforms to multi-dimensional layouts, and an extruded side provides seamless integration with the ramp surface. Includes new advanced polymer elbows for maximum fl exibility in tight closures and sharp angles.

EZ-ACCESS(800) 451-1903ezaccess.com

Outlander PlusPride’s Outlander Plus exterior lifts seek to deliver greater durability and performance to consumers who want to take their power chairs or scooters with them. The simple hitch-based installation re-quires little to no modifi cations to the vehicle. Features durable black powdercoating, a new low-profi le license plate holder and a 380-lb. lifting capacity.

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

AL 100 This scooter lift’s universal design makes it adaptable to virtually any scooter/vehicle combination. It features a sturdy aluminum deck with an adjustable cradle that extends up to 46". An auto-matic hold-down foot secures the scooter easily with no modifi ca-tions to the scooter required.

Harmar(800) 833-0478harmar.com

2500 Patient Lift This ceiling motor lift has a patient lifting capacity of 660 lbs. and operates on two rechargeable batteries. The 2500 features an emergency stop and down, and operates on various SureHands ceiling track layouts.

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

ramps & lift s marketplace

mobilitymgmt.com 29 mobilitymanagement | november 2012

ad index

Alumiramp . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Aquatic Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

ATG Rehab . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Columbia Medical . . . . . . . . . . . . . . . . . . . . . . . . 19

Diestco Corp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Freedom Designs . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Gerber Chair Mates . . . . . . . . . . . . . . . . . . . . . . . 23

Lowe’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Ottobock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2, 5

Out-Front . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

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

SKYLINK Group. . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

The Mobility Project. . . . . . . . . . . . . . . . . . . . . . . 13

Wenzelite Re/hab . . . . . . . . . . . . . . . . . . . . . . . . . 21

Karen Cavallo(760) 610-0800

Nat’l Sales Manager Caroline Stover(323) 605-4398

Sales Assistant Lynda Brown(972) 687-6710

Advertising Fax (866) 779-9095

advertisers’ index

Company Name Page #

ramps & lifts marketplace

Bruno Independent Living Aids . . . . . . . . . . . 28

Diestco Mfg. Corp. . . . . . . . . . . . . . . . . . . . . . . . . 28

EZ-ACCESS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Harmar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Lowe’s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Prairie View Industries . . . . . . . . . . . . . . . . . . . . 28

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SureHands Lift & Care Systems . . . . . . . . . . . . 28

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30 mobilitymgmt.comnovember 2012 | mobilitymanagement

Medicare’s Pricing, Data Analysis & Coding contractor (PDAC) has announced that

the implementation date for a new K0009 coding policy for manual wheelchairs has been postponed.

“Previously it was communicated that DMEPOS products listed on the PDAC Web site with HCPCS code K0009 will be end dated eff ective September 30, 2012,” the PDAC Web site said in a Sept. 11 posting. “This eff ective date has been changed. The new eff ective date will now be February 28, 2013.”

The K0009 HCPCS code is currently defi ned as “Other manual wheelchair/base.” Starting March 1, “the only products which may be billed to Medicare using code K0009 are those for which a written coding verifi cation has been made by the PDAC contractor and that are listed in the Product

Classifi cation List in DMECS maintained on the PDAC Web site,“ the PDAC now says. “Products which have not received coding verifi cation review from the PDAC must be billed with code A9270.”

Manufacturers who produce manual chairs currently coded K0009 “will still be required to submit a new coding verifi cation application to the PDAC for review and assignment of the correct code,” the PDAC added.

All of this began, the PDAC said, because the DME MACs were informed that some products currently coded as K0009 “have not been updated with the most current codes available.”

For more information on correct coding of products, visit the PDAC Web site (https://www.dmepdac.com/) or call the Contact Center at (877) 735-1326 from 8:30 a.m. to 4 p.m. Central time, Monday-Friday. ●

With Medicare’s prior authorization demon-stration project for power mobility devices

(PMD) under way in seven states, stakeholders continue to look for guidance that could stream-line the authorization process and minimize the negative impact on benefi ciaries and suppliers.

In a Sept. 19 news announcement, National Government Services (NGS), the Jurisdiction B DME MAC, released a prior authorization checklist “created in order to assist suppliers and physicians when submitting a power mobility device prior authorization request.”

The checklist, which repeats much of the mate-rial found in Medicare Learning Network Matters document SE1112, is divided into fi ve major sections: Face-to-Face Examination, Medical Records, Detailed Written Seven-Element Order, Detailed Product Description and Additional Documentation (Home Assessment).

The checklist walks physicians through, for instance, the face-to-face exam, with boxes to be checked for actions such as collecting present and relevant past medical histories (“Symptoms, diag-noses, progression, ambulation, strengths, what has changed”) and conducting a mobility-related physical exam (“Height, weight, cardiopulmonary exam, range of movement, arm and leg strength”).

The checklist also explains that the physi-cian may refer the patient to a clinician trained in conducting mobility exams, such as a PT or OT, who can then perform part of the face-to-face exam. The physician, the checklist continues, must review the report and either agree or disagree with the other clinician's fi ndings.

To download a copy of the checklist, go to ngsmedicare.com, use the search words “PMD checklist,” and choose “DME” from the “Please select” dropdown. ●

CMS Postpones K0009 Policy Implementation

PMD Demo Underway; Physician Checklist Released

briefl y…Th ere are two new Medicare fact sheets available from the Medicare Learning Network: Medicare Enrollment Guidelines for Ordering/Referring Providers, and DMEPOS Quality Standards. Both are available in download-able format from the DME MACs; the DMEPOS Quality Standards booklet is also available in hard-copy form… Starting Oct. 1, suppliers have the option of mailing or faxing hard-copy documen-tation to support DME claims submitted electronically. CGS, the Jurisdiction C DME MAC, described the process this way in a Sept. 14 bulletin: (1) Before submitting the electronic claim, complete the paperwork (PWK) section. Use “BM” if you'll mail documentation, or “FX” if you’ll fax it. (2) Aft er CEDI has accepted the claim, complete the PWK fax/mail cover sheet. (3) Mail or fax the PWK fax/mail cover sheet along with all neces-sary documentation. (4) Th e claim will be processed by the DME MAC, which will refer to the PWK documentation… Using the PWK segment is voluntary, and the DME MACs are asking suppliers to only submit the documentation as needed. Says the CGS Web site, “Medicare rules and regulations require that you keep certain documentation on fi le in order to support the medical neces-sity and justifi cation of your claims (detailed written orders, proof of delivery, etc.); however, you are not required to submit this documentation with your claim. We encourage you to only submit supporting claim docu-mentation when you believe we require it in order to correctly process your claim.” ●

cms update

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