SAMPLE

Wheelchair Evaluation

 

Client:                                                                                                 Vendor Pref: Med.

 Rec.#:                                                                                                Insurance Co.: Med/DHS

Attending Physician:                                                                         Date of Injury/Onset: 

Social Security #:                                                                              Birth Date:

 

Patient Goals:  To get a more effective seating system.

 

Diagnosis:  Cerebral Palsy (343.9)

 

Treatment Diagnosis: ICD 9 CODE: V53.8, 780.9

 

Subjective/General Information (Per Client/Family member/Care giver): 

           General Information/Social History:  Client is a 39 year old female with cerebral palsy who lives with her parents with some caregiver assistance.  The chief complaint is that the client is not safely staying in her seating system.  More specifically, per the client’s mother, she is collapsing to the right necessitating  adding pillows to try to keep her upright and in midline.  Also, due to the client’s athetosis, she is sliding out of her chair requiring constant repositioning and safety issues for transportation on Handi-van.

            

           Past Medical History:  No significant recent medical history.  Client is diapered.  Client feeds herself.

 

Transportation:   Handivan

 

Architectural Barriers:  Home is accessible-no stairs for entry

           

           Current Wheelchair System and seating system:  Client attended the session seated in an Invacare Neutron R32LX with Jay2 seat cushion with towels stuffed under the front to create an anti-thrust effect, Jay back with a right lateral, one ineffective positioning belt, rolled up towels on both sides of her seat acting as hip guides, a foam pillow between her left side and the back of the chair to keep her from falling to the left, and elevating leg rests with foot plates removed and a pillow spanning across with strap keeping left leg on right leg rest.

                                                                                                           

Objective Information

 

            Range of Motion: 

           Hip Flexion (0-125 degrees normal): No limitations for seating.

           Knee Extension with Hip at 90 degrees (or at available hip flexion): Client’s knees are held in extension most of the time due to high tone in leg muscles, requiring support from elevated leg rests.

            Strength/Motor Control:  Client has fluctuating muscle tone in all extremities and trunk with athetoid type movements. 

           Visual/Perceptual Skills: Functional for Mobility              

           

           Sensation/Skin: 

                  History of Skin Breakdown: None

                  Pressure Reliefs: Client is basically dependent for pressure reliefs, but minimally shifts weight in seat due to athetoid movements.

                  Sitting Tolerance:  12-14 hours

 

            Functional Mobility:  

            Wheelchair Propulsion:  Dependent

           Motorized Propulsion: Independent indoors and outdoors.  With extra time client is able to manage to open a door, but most of the time people assist her.

                      Ambulation: Unable

                      Standing Balance: Unable

                      Sitting Balance:  Poor

                      Transfers: Dependent

           

            Sitting Posture: Client has fluctuating muscle tone and she tends to lean to the side—mostly to her left partially due to a scoliosis with rotational component and right apex.  She also has constant extremity movement fluctuating between flexion and extension, although she holds her left upper extremity primarily into extension.  She has a positive extensor thrust when excited which promotes sliding out of her chair.

          

Assessment:   The client’s chief issue is difficulty with seating system due to her constant fluctuating tone and  spasticity decreasing her ability to maintain mid-line orientation affecting her ability to interact with her environment including motorized wheelchair propulsion as well as causing issues of sliding out of her wheelchair which is a safety issue with transportation via Handi-van as well as decreasing her independence due to needing constant repositioning to avoid sliding down and out of her chair.  Seating solutions are challenging in these situations that involve constant changing/fluctuating muscle tone with involuntary spontaneous movement.  The goal and below recommendations attempt to give the client postural security and greater trunk/proximal stability for greater control of her wheelchair and greater ability to interact with her environment without completely restraining the client and robbing her of freedom of movement.  The below recommendations also take into considerations of prior seating modifications that were not effective. The client will require a custom system to meet the desired goal of the seating system.

 

Recommendations:      

1. Freedom Design  back support: 1 &1/2” T-Foam-medium with curved modification (contour) with I Modification and swing away lateral trunk supports and tracks for lateral trunk supports to provide client with appropriate trunk and postural support to help correct postural deviations and prevent progression of scoliotic changes.  See measurements of client for dimensions as well as overall width dictated by overall width of the chair frame.
2. Freedom Design custom seat with the following features:  1” Sunmate Foam Seat with drop Hooks.  Seat- sealed incontinence liner Contour seat with foam adductors (12” apart serving as hip guides) with anti-thrust design (4” front height 2” back height) to provide client with stable base of support and assist in correcting pelvic deviations and to allow modification for higher front seat height to help keep client from sliding out of the wheelchair due to her constant movement into full body extension. Also requires Lateral hip/Thigh supports to control Les.
3. Bilateral Leg Box with mounting hardware.  Width of box is based on the width of the chair.  Recommended leg box height of 8” and depth 6”.  Goal is to adequately support the lower extremities without complete restraint
4. Dynamic anterior/posterior thoracic support vest with adjustable strap risers to provide client with upper trunk stability and prevent client from falling forward.
5. Squeeze release buckle with streamline 2 pt padded dual pull belt for lower trunk stability in system and to assist in preventing sliding out of system. 

 

Plan:  Make recommendations to client’s physician and to order the appropriate equipment through client’s vendor preference following authorization from the insurer or following approval from the client’s physician.

 

Client will require return follow-up to the clinic once the appropriate equipment is received for modification and adjustments due to the client’s clinical presentation and health risks.  The modifications required are beyond the scope of what DME suppliers can provide due to the client’s medical issues of concern.

 

 

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