Page 20 - Mobility Management, February 2019
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                                 ATP Series
Stroke Interventions
Investing in the Details
If a stroke client and the seating and mobility team do want to pursue a more functional choice, such as a K0005, Prewitt suggested demonstrating the possibilities between a standard manual chair and a more adjustable one.
“The person can make it from the dining room table to the kitchen sink,” he said as an example. “But with [a standard] chair, they can do that one time. Does that totally fatigue them for the next four hours? Does that prevent them from being able to do the next activity of daily living (ADL)? Maybe there’s something further that could be gotten into in a greater level of detail: ‘Yes, they can do that, but then they’re too fatigued to do these other mobility-related ADLs. If we put them in different equipment, maybe something with an adjustable axle or that is fit better and a little bit more effi- cient, then they could do that ADL and the next one.’”
Pucci agreed: “I think that’s a valid point. When we look at lower-level pieces of equipment, we might be able to set that chair up to see improvement in one ADL at the expense of
another. For instance, a lot of individuals post-CVA foot propel. Maybe we can get a lower-level chair in a hemi seat-to-floor height to allow them to get feet to the ground to foot propel.
Or a lot of individuals propel with one foot and one upper extremity. But by lowering that seat-to-floor to allow effective propulsion, now that individual is not able to do their transfers. They’re not able to transition from sitting to standing from such a low level.”
The Tilt-in-Space Possibility
For some stroke clients, a manual tilt-in-space chair could offer additional functionality. And the E1161 also offers a potential advantage from a medical justification perspective.
“When you’re looking at the E1161 code,” Prewitt said, “you don’t necessarily have to go through that hierarchy of ruling out all the lesser pieces of equipment. If [the client] would benefit from a tilt-in-space chair to help them with one or more of those mobili- ty-related ADLs, then they can qualify for that E1161 code.”
 How Stroke Presents: Seating & Mobility Considerations
   When laypeople think of cerebrovascular accident (CVA) or stroke, they probably envision weakness or paralysis on one side of the body — clinically known as hemipa- resis or hemiplegia.
But there are other possible effects of stroke that can impact the mobility systems that clinicians and ATPs choose.
The Impact of Stroke
Linda Bollinger, DPT, PT, ATP, is Clinical Education Manager at Sunrise Medical.
“The effects of stroke are quite signifi- cant,” she said. “A CVA will not only affect cognition, but also movement in one or all extremities due to paralysis and/or spas- ticity, vision, communication, apraxia, to name a few. All of these effects will impact independent mobility. These effects are what make the assessment process more difficult and lengthy. You cannot just order a standard wheelchair and expect that the individual will be independent.”
Stroke clients could also need help with pressure relief.
“They may have loss of sensation on their affected side,” she explained. “In addition, the neurological damage may result in orthopaedic asymmetries causing unequal weight bearing. This may require the need for reminders to weight shift (i.e., leaning forward or standing up).
“Passive weight shifts using a tilt/recline wheelchair is also an option; however, this will impact independent mobility. Therefore, weight shifting may also be a justification
for a power wheelchair. Assessing for power requires a separate evaluation process with considerations of the effects of a stroke, but also with accessibility.”
Neurological Changes
Curt Prewitt, MS, PT, ATP, is Director of Education for Ki Mobility.
“Some of the things you’ll see from people who’ve had a stroke is one side of their body is affected,” he said. “You can have weakness or paralysis on one side. You might have cognitive neglect of that side, an important effect to be aware of.”
With cognitive neglect, a stroke client might be unaware of what’s happening on the affected side. Such a client might, for example, fail to look to his left before turning his wheelchair.
“A lot of that [impact] might tie into their communications abilities,” Prewitt added. “They might have expressive or receptive problems with communication. But just because they can’t communicate or under- stand communications doesn’t necessarily mean they’re not intact otherwise to make appropriate decisions.”
Prewitt said some clients with cognitive
neglect can learn to pay special atten- tion to the impacted side of their visual field, while others cannot. Still, he said it’s important not to assume that stroke renders all clients completely incapable.
“Just because they’ve got [cognitive effects], don’t think they’ve lost the ability to make safe decisions,” he said. “The therapist and physicians should be reasonably exploring those possibilities and allowing that person to fulfill as much potential as they’ve got left, rather than assuming they can’t do it.” m

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