Wheelchair Seating and Mobility

I. Evaluating the Client to Determine Seating and Mobility Needs

A. Goals for seating and wheeled mobility systems (Cook & Polgar, 2012, p. 68; Dudgeon &
Deitz, 2008, p. 491)
1. Bodily structures and function: improve skeletal alignment; prevent, reduce, or accommodate de-
formity; preserve skin integrity; maintain physiological function of vital organs (respiratory, circula-
tory)
2. Function: enable sitting (postural control and stability) and wheeled mobility, increase comfort (de-
crease discomfort or pain), normalize muscle tone, position head for visual input, decrease fatigue
3. Activity and participation: enhance movement to enable or optimize participation in self-care, edu-
cational, work, and play and leisure occupations; promote social acceptance and self-esteem

B. Members of the team for prescribing seating and wheeled mobility systems (Tipton-
Burton, 2013, p. 242)
1. Client: indicates needs and develops and prioritizes goals for the seating and mobility system
2. Physiatrist: provides information on the client’s medical history and current diagnoses, prognosis,
and contraindications
3. Occupational or physical therapist: provides expertise in seating and mobility system evaluation,
selection of system, and wheelchair training
4. Rehabilitation engineer: provides information about the technological capabilities of seating and
mobility systems
5. Assistive technology vendor: informs about available and emerging durable medical equipment and
its capabilities and properties

C. Service delivery process for seating and mobility systems (Cook & Polgar, 2012, pp. 68–
74; Dudgeon & Deitz, 2008, pp. 489–499)
1. Referral
2. Evaluation of need
a. Occupational profile
b. History-taking interview
c. Observation
d. Physical examination
3. Recommendations for seating and mobility system, including client’s compliance
4. Documentation of need
5. Ordering the system
6. Fitting system to client

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 7. In-clinic training and environmental training
a. Client
b. Caregivers and attendants

D. Determination of the client’s seating and mobility needs and goals: history-taking
interview (Cook & Polgar, 2012, pp. 68–74; Dudgeon & Deitz, 2008, pp. 489–490; Tipton-
Burton, 2013, pp. 242–243; Vancouver Island Health Authority, 2004, pp. 3–4)
1. Goals: What does the client want to achieve with the system? How are these goals prioritized?
2. Medical diagnoses and status: What is the referring medical diagnosis? Does it lead to permanent
disability (e.g., spinal cord injury) or temporary disability (e.g., fractures)? Is the client’s condition
expected to get progressively worse? to improve? to remain stable?
3. Body structures and functions: How much does the client weigh? Does the client have any deformi-
ties, loss of sensation, pressure ulcers, pain, abnormal muscle tone, or visual loss or deficits?
4. Occupations: What occupations (self-care, education, work, play and leisure) will the seating and
mobility system be used for? How active is the client?
5. Physical context: In what physical environments will the system be used? How accessible are they?
How will the seating and wheeled mobility system be transported from place to place? What differ-
ent surfaces and terrains need to be considered?
6. Social context: Who is available to assist the client in using the system in each of the physical envi-
ronments in which it is to be used? When are they available? How skilled are they in assisting the
client and in maintaining the seating and mobility system?
7. Physical skills: Can the client maintain a seated position independently, maintain head alignment,
and perform transfers independently? Does the client have the upper-extremity strength and physi-
cal endurance required to operate a manual wheelchair? Has the client fallen recently?
8. Cognitive–behavioral skills: Does the client have the cognitive ability to learn to use the system?
Does the client have sufficient safety awareness to use the system?
9. Equipment: What technology does the client currently have? What is the client’s familiarity with
seating and wheeled mobility systems? What equipment will need to be attached to the system (e.g.,
respiratory, communication, lapboard)?
10. Payment: What seating and mobility systems are approved by the client’s health insurance? Are
other sources of funding available?

E. Determination of the client’s musculoskeletal and neuromuscular capacities: physical

examination (Cook & Polgar, 2012, pp. 70–71; Vancouver Island Health Authority, 2004,
pp. 5–14)
1. Observe the client’s posture and stability in the current seating system (baseline position); check
postural alignment and deformity.
2. Transfer the client to a seated position on a mat table.
a. Observe the transfer, including the position and control of the upper extremities and head and
neck.

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 b. Observe the client’s seated position when unsupported (Cook & Polgar, 2012, p. 71).
i. Hands-free sitter: Client can maintain a seated position without using the hands. The seat-
ing system design emphasizes mobility, stability (stable base of support), and comfort.
ii. Hands-dependent sitter: Client uses one or both hands to maintain a seated position. Pelvic
and trunk support is required of the seating system to free the hands for activities.
iii. Propped sitter: Client lacks the ability to sit without support. Total body support is required
of the seating system for posture and repositioning.
c. Observe the position of the client’s pelvis and trunk.
i. If deformities exist, apply manual pressure to determine whether the deformity is flexible or
inflexible (Cook & Polgar, 2012, p. 70).
ii. A flexible deformity can be reduced to some extent by a supportive seating system; an inflex-
ible or fixed deformity needs to be accommodated with a seating system.
• Pelvic obliquity: One side of the pelvis is lower than the other side, which can lead to scoliotic
posture and pressure ulcers on the ischial tuberosity.
• Kyphosis: The pelvis rotates posteriorly, resulting in sacral sitting and flexion of the lumbar spine;
clients tend to slide forward on the seat.
• Scoliosis: The pelvis rotates to one side, resulting in the spine and trunk moving to the opposite
side.
• Lordosis: The pelvis rotates anteriorly, increasing the curvature of the lumbar spine; clients tend
to use upper extremities for support.
• Windswept deformity: The pelvis rotates laterally, with the thighs moving to the other side.
d. Observe and assess upper and lower extremities (seated or supine).
i. ROM for manual propulsion and for sitting upright (90° hip flexion)
ii. Strength for manual propulsion
iii. Quality of movement, presence of tone, spasticity, tremor, primitive reflexes
e. Reposition the client in supine.
i. Reassess pelvic and spinal alignment because the influence of gravity on the body is different
in supine than in a seated position.
ii. Check for signs of pressure or shear on skin or pressure ulcers.

II. Positioning and Seating: Matching the Client to System Technologies

A. Seating principles (Cook & Polgar, 2012, pp. 74–82; Dudgeon & Deitz, 2008, p. 491)
1. Seating and wheeled mobility: Seating forms the interface between the client and the mobility de-
vice.
2. Seated position: The reference seated position is as follows: The trunk is upright and in midline
position; the hips, knees, and ankles are flexed to 90°; the pelvis is in neutral; the head is in midpo-
sition; and the arms are at the side of the trunk with the elbows flexed to 90°.

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 3. Sitting as a dynamic posture: People move frequently when sitting to maintain comfort and to
achieve a suitable position for an activity. Prolonged sitting in one position can lead to pressure
ulcers, back pain, joint contractures, lower-extremity edema, and postural deformities.
4. Seating biomechanics: When people are seated, the pelvis and thighs provide the base of support
for stability and movement. The pelvis can tilt and rotate, which introduces instability and influ-
ences the position of the spine, trunk, upper extremities, and head. Pelvic positioning is the key to
stability (Cook & Polgar, 2012, pp. 77–82).
a. Provide a solid base of support by stabilizing the pelvis on a firm surface, which distributes pres-
sure throughout the buttocks and thighs.
b. Support posture with the seat and seat back. Provide cushioning for these surfaces.

B. Cushioning for seat and back surfaces (Cook & Polgar, 2012, pp. 87–90; Dudgeon & Deitz,
2008, pp. 491–492)
1. Selection factors: The seat supports the pelvis and thighs; the back supports the posterior pelvis and
spine. Cushioning reduces peak pressures of bony prominences and evenly distributes pressure over
a larger area, affects postural control and transfers, and can accommodate deformity, and its com-
position has varying ability to manage moisture, heat, and friction. Consider durability and mainte-
nance requirements.
2. Pressure measurement: To determine the comparative effectiveness of different cushions for reliev-
ing pressure on the seating surface, pressure mapping is done by inserting a pressure-sensitive mat
between the client and the seating surface (Cook & Polgar, 2012, p. 86).
3. Cushion shape
a. Flat (planar) surfaces do not accommodate body shape. They are appropriate for clients who
need no or minimal postural support and can reposition themselves independently.
b. Standard contoured surfaces have contours based on typical body sizes. They provide more
support than flat surfaces, distribute pressure across their surface, and are less expensive than
custom-made surfaces.
c. Custom-contoured surfaces are shaped to a client’s body. They provide the most support, dis-
tribute pressure across their surface, and are more expensive than standard contoured surfaces.
Disadvantages are that clients are limited to one position, transfers are more difficult to per-
form, and the system is not adaptable (e.g., cannot accommodate a child’s growth). They are
appropriate for clients who need support to maintain balance, have pelvic or spinal deformities,
have muscle tone abnormalities, or need additional lumbar support.
4. Cushion materials (Cook & Polgar, 2012, pp. 91–93; Dudgeon & Deitz, 2008, pp. 492–493)
a. Foam: Foam is of variable density. Foam that is soft and pliable will mold itself around the
buttocks. If it is too soft, the client may totally compress it, making it useless for pressure man-
agement. Foam cushions are lightweight and low cost; however, heat and moisture can build
up. Custom-contoured foam is more expensive and provides better postural control; shearing is
reduced, and weight-shifting capability is reduced.
b. Gel filled: These cushions conform to the shape of the buttocks; they are adequate for postural
control, heavy, and sensitive to temperature.

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 c. Air filled: These cushions are lightweight; they provide even pressure relief but have to be prop-
erly inflated to perform well. They also reduce postural stability.
d. Honeycomb-shaped plastic: The cushions provide uneven pressure relief and are lightweight.
e. Hybrid: These cushions incorporate a combination of materials, typically foam and gel.
f. Alternating pressure: These cushions provide scheduled pressure relief through alternating
levels of inflation and deflation; they also reduce postural stability.

C. Additional seating supports (Cook & Polgar, 2012, p. 88)

1. A pelvic stabilizer (belt, SubASIS bar) is positioned at the front of the pelvis to limit pelvic tilt, rota-
tion, or obliquity.
2. Thoracic supports are placed lateral to the trunk and below the armpit to facilitate trunk stability
and prevent or slow scoliosis; anterior trunk supports are situated below the top and above the bot-
tom of the breastbone.
3. Thigh supports are placed lateral or medial to the thighs to control abduction or adduction (e.g.,
windswept deformity).
4. A head rest supports the back of the head and is positioned at the occiput.

D. Measuring clients for a chair (Dudgeon & Deitz, 2008, pp. 500–501; Tipton-Burton, 2013,
pp. 248–249)
1. The client’s physical dimensions largely determine wheelchair size and features.
2. Sizing measurements should be taken while clients wear the braces, prosthetics, or orthotics they
usually wear.
3. Clients should be seated in the style of wheelchair and with the type of cushion that is similar to or
simulates the one to be used.
4. The following measurements are taken:
a. Seat width: Measure the widest part of the thighs or hips, and add 1–2 inches. The added width
provides clearance between the thighs and chair to ease repositioning and transfers, avoid rub-
bing or pressure, and accommodate bulky clothing.
i. The goal is to distribute body weight over as much of the seat as possible.
ii. In the presence of deformity, chest and shoulder width should be measured and space al-
lowed for any lateral trunk supports.
iii. If the seat is too narrow, it will be uncomfortable and there will be added pressure on the
thighs.
iv. If the seat is too wide, it will facilitate leaning to the side; arm abduction will be increased for
manual propulsion.
b. Seat depth: Measure from the base of the back to the popliteal space of each knee; subtract 1–2
inches so that the seat edge does not reach the back of the knee and restrict motion or circula-
tion. Measure both lower extremities to account for discrepancies in length.
i. The goal is to distribute body weight along as much of the thigh as possible.
ii. To allow wheelchair propulsion with the feet, seat clearance of more than 1–2 inches may be
needed.

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 c. Seat height: Measure from the popliteal space to the bottom of the client’s heel. Footrests
should have a 2-inch clearance from the floor.
i. The goal is to keep the thighs parallel to the floor, the feet resting comfortably on the foot-
rests, and the footrests clearing the floor.
ii. Note that the seat cushion raises the overall seat height.
d. Seat-back height: Measure from the seat surface (including the cushion) to the top of the client’s
shoulder; a higher back height may be needed if trunk control is poor.
i. Measurement depends on the degree of back support needed for trunk control, comfort, and
upper-extremity activity, including propulsion.
ii. The goal is to provide the support needed, allowing as much upper-extremity movement as
possible.
iii. If minimal trunk support is required, measure from the seat surface (including the cushion)
to the midback, just under the scapulae.
• If the seat-back height is too low, the client will not have sufficient back support.
• If the seat-back height is too high, contact with the push rim will be limited.
• Lower back height (e.g., in sports chairs) increases functional mobility but decreases stability.
iv. For power wheelchair users, back heights to midscapula or the top of the shoulder may be
needed to attach upper trunk and head supports.
e. Seat and back angle
i. Seat angle: Sloping the seat down toward the rear of the wheelchair (seat dump) can help
stabilize the pelvis. Too much sloping can make transfers difficult and cause pressure.
ii. Back angle: The back can be reclined to ease discomfort associated with hip flexion. Too
much of a backward angle makes the chair unstable.
f. Armrest height: Measure from the seating surface to the bottom of the client’s flexed elbow; the
armrest should be about 1 inch higher.
i. The goal is to support the upper extremities, provide leverage for pushing up for pressure
release, and assist in maintaining postural alignment.
ii. If the armrest is too low, it elicits leaning.
iii. If the armrest is too high, it positions the shoulder in elevation.

III. Mobility: Putting the Client in Motion

A. Characteristics of clients requiring support for mobility (Cook & Polgar, 2012, p. 267)
1. Marginal ambulatory user: can walk short distances; may need a wheelchair on occasion, especial-
ly outdoors; can benefit from intermittent use of a power mobility device such as a scooter
2. Manual wheelchair user: can propel a manual wheelchair with both upper extremities, both lower
extremities, or one upper and one lower extremity or is pushed by an attendant or caregiver
3. Marginal manual wheelchair user: can propel a manual wheelchair for short distances; tolerates
only limited use because of upper-extremity overuse injury, upper body weakness, lack of endur-
ance, or respiratory problems; may at times use a manual or power wheelchair

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 4. Totally or severely mobility-impaired user: is unable to self-propel a manual wheelchair; is depen-
dent on a power chair or attendant

B. Wheelchair supporting structures (Cook & Polgar, 2012, pp. 270–272; Dudgeon & Deitz,
2008, p. 491)
1. Frame: The material the frame is made of (steel, aluminum, titanium) affects chair weight; its struc-
ture (fixed, folding, electric) affects its durability, storage, and transportability.
2. Seat
a. The seat is commonly a vinyl sling seat; it is lightweight and folds and cleans easily. It fosters
pelvic instability and thigh malalignment.
b. To provide pelvic stability, a solid seat is inserted on top of the sling seat; cushions are placed on
top of the solid seat.
c. The seat may be dropped on the frame to enable clients to foot propel.
3. Backrest: Backrests are typically made of flexible material; solid inserts are available.

C. Types of wheelchairs (Centers for Medicare and Medicaid Services [CMS], 2009, 2013a,
2013b; Dudgeon & Deitz, 2008, pp. 494–498; Noridian Healthcare Solutions, 2013;
Tipton-Burton, 2013, pp. 244–247)
1. Transporter chairs are designed to be pushed by an attendant or caregiver. These chairs have
smaller rear wheels, making them lighter and easily transportable. They are used for short distances
or temporary use.
2. Manual chairs are self-propelled or pushed by an attendant or caregiver. To self-propel for long
distances, clients must have adequate upper-extremity strength and endurance to push and brake.
A manual chair can also be propelled with one arm and one foot or with both feet. Long-term self-
propulsion may lead to repetitive motion injury.
a. Standard chairs (Medicare product code K0001) are meant for short-term, temporary use (e.g., if the
regular chair is in for repair or the client lacks judgment to self-propel). These chairs fold, the seat and
back are sling upholstery, and the rear axle is fixed. They are heavy (typically made of steel; ³35 lb) and
have limited adjustability.
b. Lightweight chairs (Medicare product code K0003) have features similar to those of a standard wheel-
chair but are lighter in weight (often made of aluminum; <35 lb). Adjustability is limited.
c. Ultra lightweight chairs (Medicare product code K0005) weigh <30 lb. They are available with rigid or
folding frames, both of which fold for transport. They have an adjustable axle and quick-release wheels
and are customizable.
d. Heavy duty chairs (Medicare product code K0006 for clients >250 lb, K0007 for clients >350 lb) are
designed to be bigger and stronger for clients who are obese or have severe spasticity.
3. Scooters are for clients whose walking ability is limited. Scooters have three (usual) or four wheels
and are steered with a tiller. They do not look like wheelchairs and are more difficult to steer than
power wheelchairs. They have a large turning radius, and the seat swivels, which may make trans-
fers easier. They have limited adjustability.
4. Power wheelchairs are for clients who cannot propel a manual wheelchair or for whom propelling
a chair is contraindicated. These chairs have seating and power components (i.e., motor, wheels,

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 batteries). The drive wheel may be placed at the front, middle, or rear; middle placement generally
means a smaller turning radius. Movement is controlled through a joystick or alternative control
type (e.g., breath, head, chin, eye, tongue). Multiple seating options are available ranging from
automotive-type captain’s seats to seats that tilt, recline, elevate the leg rests, or stand.
a. Chairs that recline and tilt are for clients who have hip contractures, need to recline to reduce
pressure or manage fatigue, or cannot reposition themselves independently or are unable to
maintain an upright seated position. They assist in managing ROM, muscle tone, orthostasis,
catheterization, and head and trunk control and in enabling visual contact.
i. Tilt: Seat-to-back angle is fixed; the seating system can be tilted 0°–45°, changing orienta-
tion in space but not position, thus preventing shear while reducing pressure on the but-
tocks. This feature is recommended when control devices (communication) need to be
attached to wheelchair and eases personal care activities.
ii. Recline: The seat-to-back angle changes to more than 90°, ranging from upright to nearly
horizontal. This feature is appropriate for clients who are unable to sit upright (e.g., because
of hip restrictions) or who spend considerable time in a wheelchair and need to rest during
the day. This feature eases personal care activities.
iii. Tilt and recline functions may be combined.
b. Chairs can be manually or power controlled.
c. Chairs may have elevating leg rests.
5. Chairs that stand enable clients to be totally supported while standing and can be manual or power.
Benefits are as follows:
a. Physiological: Standing improves circulation and bowel and bladder functions, reduces lower-
extremity spasticity, and provides pressure relief.
b. Functional: Clients can more easily reach items higher than seated level. Independence is in-
creased, and some home and work adaptations may be avoided.
c. Social: Person-to-person interactions can occur at face-to-face level, which has a psychological
benefit.
6. Chairs for specific populations (Tipton-Burton, 2013, pp. 249–250)
a. One-arm drive chairs (Medicare product code K0002) are for clients with hemiplegia or one
arm amputated. Axles are linked to allow both wheels to operate from one side.
b. Hemi-height chairs (Medicare product code K0002) are for clients with hemiplegia. Chair
height is lower to permit foot propelling. The foot rest for the nonhemiplegic extremity is re-
moved.
c. Extra heavy-duty chairs (Medicare product code K0007) are for clients who are obese and need
larger, stronger chairs (rated for weight >300 lb) to accommodate their weight. Compared with
standard chairs, the rear axle is displaced forward. These chairs have hard, extra wide tires.
d. Pediatric chairs are designed for the dimensions of children and for accommodating growth.
e. Amputee chairs, because amputation moves the client’s center of gravity back when seated, have
the rear axle set back to increase stability, which compensates for the loss of weight of the miss-
ing limb or limbs.
f. Sports chairs are very lightweight chairs (<20 lb) designed for specific sports.

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D. Wheelchair propelling structure (Dudgeon & Deitz, 2008, pp. 498–501; Tipton-Burton,
2013, pp. 250–252)
1. Wheels
a. Rear wheels are usually the larger wheels; they are equipped with push rims.
b. Tires may be rubber (little maintenance) or pneumatic or semipneumatic (air filled); tires ab-
sorb shock and require maintenance to keep filled with air.
c. Rear wheels are attached to the frame with a fixed or adjustable (forward–backward, up–down)
axle.
d. Casters are the smaller wheels, usually rubber, located on the front of the chair.
i. They rotate freely, making steering feasible.
ii. Larger casters give a more comfortable ride; they are less likely to get stuck in a hole.
e. Clients apply a forward or backward motion to the push rims with the upper extremities to pro-
pel the chair; braking is done by applying pressure to the push rims or dragging the feet.
f. Stability and maneuverability of a wheelchair is affected by the position of the drive wheels’ axle
in relation to the client’s center of gravity.
i. The chair is more stable when the client’s center of mass is ahead of the drive wheels’ axle.
ii. The chair is more easily moved when the client’s center of mass is close to or slightly behind
the drive wheels’ axle.
iii. When the axle is aligned below the shoulder, access to the push rims is improved. Movement
efficiency is increased because the user can go further with fewer strokes.
iv. Moving the axle up relative to the seat lowers seat height, which improves stability; if the
seat is too low, poor propulsion patterns may result because of abducted arms.
g. Quick-release wheels can easily be removed for storage and transport.
h. Power-assist wheels have a motor in the wheel hub. When the client pushes on the push rim, the
motor starts and propels the chair in the direction of the push; these wheels decrease the effort
needed to push.
2. Brakes: Levers attached to the frame press on the tire when engaged to stop the rear wheels from
moving; push and pull locks are available.

E. Wheelchair components (Dudgeon & Deitz, 2008, p. 501; Tipton-Burton, 2013, pp. 250–
252)
1. Armrests: support the arms and facilitate push-ups for pressure release
a. Armrests are a fixed part of the frame and provide a stable surface for push-ups. Removable
armrests facilitate side transfers and use of a transfer board and improve access to work surfac-
es.
b. Height-adjustable armrests promote comfort; if they are too high or too low, they may cause up-
per body discomfort.
c. Full-length armrests provide more support for arms and better support for a lap tray than
shorter ones; they promote ease of arm use for transfers.

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 d. Desk-length armrests have a shorter length to improve access to work surfaces; by reversing the
armrest, a lapboard can easily be accommodated.
2. Leg rests and footrests (front rigging): support the legs and feet
a. Leg rests and footrests are a fixed part of the frame.
b. Swing-back and removable leg rests and footrests provide a clear path for transfers; they allow
the feet to reach the floor to prepare for transfers.
c. They may flip up and down and may be angle adjustable.
d. They may adjust to different leg lengths.
e. Elevating leg rests and footrests permit repositioning for comfort; however, because the lower
extremities need to be above the heart for edema control, elevated leg rests provide little benefit
for edema control.
f. Ankle straps keep feet from slipping off footrests.
g. Heel loops prevent feet from slipping off the back of footrests.

F. Common wheelchair accessories (Dudgeon & Deitz, 2008, p. 492)

1. Lapboard
a. Fits across the armrests to support a weak upper extremity or provide a work surface
b. Wraps around the client; reduces the overall width of the chair by about 1 inch
2. Positioning belt: stabilizes the pelvis; should be positioned so that it pulls on the pelvis at a 45°
angle to the base of the seat back
3. Hand rim projections: compensate for weak grasp in moving the wheelchair
4. Brake lever extender: compensates for limited ROM in reaching the brakes
5. Antitip devices: prevent the chair from tipping backward
6. Hill holder: prevents the chair from going backward down a grade
7. Push handles: ease pushing the chair; are height adjustable
8. Adjustable-tension backrest: replaces the sling backrest; tension is adjusted by loosening and tight-
ening the strapping system; accommodates kyphosis
9. Wedge cushion (antithrust seats): front higher than back to aid in preventing forward sliding

G. Client and caregiver–attendant training (Dudgeon & Deitz, 2008, pp. 492, 502; Tipton-
Burton, 2013, pp. 252–253)
1. Instruction topics for client and caregiver–attendant
a. Proper sitting posture, including placement of any supports
b. Pressure relief
i. Push-ups
ii. Side-to-side movement
iii. Schedule for weight shifts and skin monitoring

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 c. Wheelchair propulsion
i. Manual
ii. Power
d. Safety considerations
i. For client and caregiver–attendant
• Setting and releasing brakes during transfers
• Swinging away leg rests (footrests); not standing on footrests
• Removing armrests (if appropriate)
• Recovery from a fall
ii. For caregiver–attendant
• When pushing, make sure that the client’s arms, hands, and feet are secure.
• To ascend curbs, tilt the chair backward to lift the casters onto the curb, then push for-
ward until the large rear wheels roll over the curb.
• To descend curbs, move the chair around to descend backward; guide the large wheels
down the curb to the street. Clear the casters by tilting the chair; and then turn the chair
to face forward.
• To ascend an incline, move the chair forward.
• To descend an incline, balance the chair backward and move in a forward direction, or go
down backward with the client controlling the speed using hands on the push rim.
• Wheelchair maintenance includes upholstery cleaning, brake checking, tire inflation, and
wheel alignment.
2. Practice propelling indoors and outdoors in tight spaces and on curbs (wheelies), ramps, and rough
terrain (Pierce, 2008, pp. 826–828)
3. Assessment of competence in wheelchair skills before discharge

H. Third-party payers (Dudgeon & Deitz, 2008, pp. 492, 503; Tipton-Burton, 2013, p. 252)
1. Justification must relate to medical necessity, including increased function, health, safety, and user
satisfaction.
2. Medicare policy regarding mobility-assisted equipment (MAE; Dudgeon & Deitz, 2008, p. 492;
Tipton-Burton, 2013, p. 252)
a. Medicare-covered clients are eligible for MAE if they have a “personal mobility deficit sufficient
to impair their participation in MRADLs [mobility-related ADLs], such as toileting, feeding,
dressing, grooming, and bathing in customary locations in the home” (CMS, 2005).
b. Clients must be able to—or have a caregiver who is able to—consistently and safely use the MAE
in the home.
i. For a manual wheelchair, they must have sufficient upper-extremity strength.
ii. For a scooter, they must have sufficient strength and postural stability.
iii. For a power wheelchair, they require those features of a power chair that are not available on
a scooter to participate in MRADLs (e.g., joystick, lower seat height).

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 c. The documentation criteria for MAE are as follows:
i. Symptoms
ii. Related diagnoses
iii. History: clinical trajectory, interventions that have been tried and their results
iv. Physical examination: height, weight, physical impairments (ROM, strength, tone), sitting
balance, spinal posture, ability to reposition
v. Functional assessment: performance of MRADLs
vi. Recommendation and rationale

References
Centers for Medicare and Medicaid Services. (2005). National coverage determination (MCD) for
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