Wheelchairs and Adapted Strollers

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What You Should Know About Wheelchairs and Adapted Strollers
Getting the First Wheelchair
Process
Funding
How to Know if a Wheelchair Fits
Follow-up

What You Should Know About Wheelchairs and Adapted Strollers

Mobility is vital to all of us. Children who cannot walk on their own need chances to move, even if they need help, to maximize their overall development. Children are curious and want to explore the world around them. Wheelchairs may help children in these ways:

Promote ability and participation with peers.
Conserve strength for children who may struggle to walk over longer distances.
Reduce the risk of caregiver injuries linked to lifting their children.

For smaller children, strollers may be the alternative to a wheelchair, and can be lifted into standard cars, unlike heavier wheelchairs.

Photo courtesy of Druidhills through Wikicommons, January 13, 2013

Strollers

Strollers are often used before a child is big enough for a wheelchair. Adaptive strollers offer a lighter and more portable choice. Strollers are often preferred for these reasons:

They are easy to load and unload from cars.
They tend to fit in places where wheelchairs may not, such as small doorways and hallways.

Ways that strollers differ from wheelchairs:

They have a more flexible than firm seat, adding to sacral pressure.
Children often need caregivers to push their strollers, but children may learn to drive manual or power wheelchairs on their own.

Specialized strollers can be designed and ordered through a seating clinic much like a wheelchair, or parents may want to buy a stroller and change it for their own needs with extra storage, straps and padding.

It is important to know that health plans usually only cover EITHER a stroller OR a wheelchair in a five-year period. If both a stroller and wheelchair are needed, some decide to pay for one out of pocket, and strollers are often less costly than wheelchairs.

For more in-depth tips and pictures about wheelchairs, strollers, carts and scooters for children with special health care needs, please see Fact Sheet on Wheelchairs for Children by AbleData.

Getting the First Wheelchair

Most children walk by 18 months of age. If a child is not mobile on their own by then, it is time to talk about other choices, such as wheelchairs. Some children with motor impairment will need positioning/seating before 18 months. The process should begin whenever a child needs support for function/mobility or a parent needs "another pair of hands."

Getting a wheelchair can be exciting and overwhelming, both emotionally and financially. It can sometimes bring up painful feelings that you may not expect. This may relate to:

Accepting a diagnosis or a permanent disability
Worry that your child will be seen as different
The need to make changes in housing or lifestyles.

Knowing you might have these feelings and working through them can be helpful.

Finding a Physical or Occupational Therapist (PT/OT)

The first step in getting the right wheelchair for your child is to find a PT/OT with seating and positioning skills (see Resources > Services below). Some therapists and vendors have RESNA Assistive Technology Certifications (ATP, SMS) in assistive technology,seating, and mobility. This certification promotes a standard of professional practice in the field. If your child receives physical or occupational therapy through Early Intervention, school, or home care, and has a therapist who knows about wheelchairs, this is a perfect fit since he/she knows the child and family.

A clinician may write two orders/prescriptions:

One for a wheelchair (or other mobility device)
One for the PT/OT or seating clinic to evaluate the child for a wheelchair and make a full prescription of the best wheelchair or stroller for the child.

See Sample Physician Order for Wheelchair or Adapted Stroller and Seating Evaluation ( PDF Document

107 KB).

Evaluation for a Wheelchair

The next step in getting the right wheelchair for your child is getting a complete evaluation. A team evaluation is recommended. All team members work closely together and make a contribution. The team may have some or all of these members:

The parents and child will steer the team with their thoughts about what may work, what has been tried before, and can point out their needs for support with mobility. At the end of the process, the choices are theirs.
The Physical or Occupational Therapist (PT/OT) will evaluate fine motor skills (hand), gross motor skills (total body), touch, and movement; seating and positioning; visual perception; oral motor skills (feeding/swallowing); and mobility needs (self-propelled manual wheelchair or powered wheelchair with a joy stick/head array) for mobility.
- They will evaluate the different settings for use (home, car, school, etc.).
- Therapists will also teach parents/caregivers how to use the wheelchair, how to take the wheelchair apart for transit, how to get the child in/out of the wheelchair, and set up training for the child to learn to use the chair.
The Speech Therapist will evaluate the child's communication skills – is an augmentative communication device needed to help increase their ability to communicate? If so, how will it be used in the wheelchair?
Rehabilitation Engineers write prescriptions for the wheelchair, and other equipment.
- These are often based on recommendations from the PT/OT.
- Sometimes referrals are needed for 3rd party payment.
Clinicians should write prescriptions for any other special health needs.
- Clinicians can help show the need for ventilator trays, and adaptations for transporting oxygen, suction and feeding bags on the wheelchair.
- Often a co-signature by the clinician on a letter of medical necessity (LMN) done by the therapist is needed. (See our Writing Letters of Medical Necessity page.)
- It may work to rent a wheelchair when the disability is temporary, such as after a surgery or injury.
Teachers, rehabilitation counselors, employers, day care providers, respiratory therapists, recreational therapists, nurses, orthotists, friends, and even architects can be useful team members to help decide what accommodations to make at home, school, and other places.
The Wheelchair/Seating Vendor's agent will send the paperwork to Medicaid or other health plan.
- They will get prior approval, order the equipment, build, and deliver it.
- Wheelchair vendors are often certified seating specialists and have good product information and know-how.
  - They can explain the pros/cons of each type of wheelchair to the parents and team.
- They can also give price quotes and cost ranges. Vendors have a repair shop where flat tires and other repairs can be made.

Process

Following the evaluation, a letter of medical necessity is written (most often by the PT/OT) to show the need for the wheelchair.

It must be co-signed by the doctor, or a prescription must go with the letter.
This is sent by the vendor to Medicaid/health plan for prior approval.

Once approval has been received, the order is made.

When it is received, a final wheelchair fitting by the team is scheduled to make sure it fits and works for the child.

From start to finish, it all takes about 3 months.

If the wheelchair is denied by Medicaid/insurance, it can be appealed.

Appeals must be done in a timely fashion.
Check the denial letter for timelines.
See the Writing Letters of Medical Necessity and Appealing Funding Denialsfor assistance in appealing.

Funding

Most wheelchairs or other assistive technologies are covered by Medicaid or private insurance as long as they meet a medical need. In general, wheelchairs can be replaced every 5 years or sooner if medical justification is documented and approved. Modifications to wheelchairs, such as for growth, are usually approved yearly. Some state agencies, charitable organizations, or private funding organizations can assist with the cost of the assessment and/or equipment.

How to Know if a Wheelchair Fits

A wheelchair fits if the child's:

Head and upper body are upright and in the center of the seat with or without support
Shoulders are over the hips and level with each other
Legs are straight or slightly open
Lower body is straight, in an even tilt, and all the way back in the seat
Weight is on the thighs and backside
Feet are on the footrest
Knees are no more than 2-3 finger widths in front of the seat edge (for a growing child)
Skin is healthy and looks unharmed – check the backside near the bottom of the spine and the back of the legs (if the seat is too deep, the child will lean back to reach the support surface, the pelvis will be in a backward tilt, and the child may have redness behind the knees)
Eyes are forward
Chest harness fits and does not cut into the neck and is not a choking hazard (the child should not be "hanging" on the harness)
Wheelchair has a snug fitting seat belt, with padding if needed
Wheelchair works correctly and is regularly maintained.
The child is comfortable for at least 2 hours at a time in the chair

Considerations

If a child has a severe impairment and/or contractures, a wheelchair may not fit as described above. With a fixed position, the seating should accommodate the child’s body. Comfort and good skin health may become the top goals.
If the wheelchair does not fit the right way, a referral to a PT/OT with seating knowledge should be made to solve the problem or suggest a new chair or other choices. If repairs are needed, the parent should call the vendor. If needed, the doctor should write a prescription/referral for the wheelchair repairs.

Follow-up

Training is essential to maximize the use of the wheelchair or other Assistive Technology (AT) device, and can be provided by the involved PT/OT. The team should follow-up with the individual to ensure the wheelchair is acceptable and meets the needs of the patient and family. It is common to have to make "adjustments" after the wheelchair has been in use for some time.

Periodic Re-evaluation

How well the wheelchair meets the child's and family's needs should be reassessed periodically by the involved therapists or other team members. Children grow, and the wheelchair needs to adapted or replaced to meet evolving needs. Medical needs, function, and preferences change with time also and each should be continually addressed. Repairs may also be needed.

Resources

Information & Support

In addition to informational links, we provide links to both not-for-profit and commercial sites offering assistive technology products and medical equipment that may help you understand the range of technology available. We do not endorse these companies, nor provide any guarantee of the quality of equipment available through these sites

For Parents and Patients

Adaptivemall.com
A commercial site offering a variety of strollers, equipment, and assistive technology products.

AbleData.com
ABLEDATA gives objective information on assistive technology and rehabilitation equipment available from domestic and international sources. Parents can look at items they are thinking about purchasing and see details and the ratings users have given for them. Sponsored by the National Institute on Disability and Rehabilitation Research (NIDRR).

Services in Nevada

Select services for a different state: ID, MT, NM, RI, UT

The search for a qualified physical therapist (PT) or occupational therapist (OT) to serve on the team should start with the child's current providers, whether they are through the school, hospital, or clinic. If they are experienced, willing to help, and relate well with the family, you need look no further. Below you will find links to lists of local providers/sources of these and other related services.

Adolescent Health Transition Programs

We currently have no Adolescent Health Transition Programs service providers listed; search our Services database for related services.

Assistive Technology Equipment

See all Assistive Technology Equipment services providers (15) in our database.

CSHCN Clinics

We currently have no CSHCN Clinics service providers listed; search our Services database for related services.

State Institutions for Individuals with Disabilities

We currently have no State Institutions for Individuals with Disabilities service providers listed; search our Services database for related services.

For other services related to this condition, browse our Services categories or search our database.

Helpful Articles

Greer N, Brasure M, Wilt T.
Wheeled Mobility (Wheelchair) Service Delivery.
Agency for Healthcare Research and Quality. Technical Brief Number 9; January 2012. / http://www.effectivehealthcare.ahrq.gov/ehc/products/194/751/TechBrief...
Report prepared by the Minnesota Evidence-based Practice Center; a review of evidence related to wheelchair service, largely focused on adult services; highlights many of the payer, reimbursement, consumer, and provider issues that are relevant also for children.

Corbet, Barry.
Spinal Network: The Total Wheelchair Resource Book.
Third Edition ed. Nine Lives Press; 2002. 0971522308
A comprehensive guide to practical information regarding living in a wheelchair.

Butler C, Okamoto GA, McKay TM.
Motorized wheelchair driving by disabled children.
Arch Phys Med Rehabil. 1984;65(2):95-7. PubMed abstract

Butler C, Okamoto GA, McKay TM.
Powered mobility for very young disabled children.
Dev Med Child Neurol. 1983;25(4):472-4. PubMed abstract

Tefft D, Guerette P, Furumasu J.
Cognitive predictors of young children's readiness for powered mobility.
Dev Med Child Neurol. 1999;41(10):665-70. PubMed abstract

Huang HH, Galloway JC.
Modified ride-on toy cars for early power mobility: a technical report.
Pediatr Phys Ther. 2012;24(2):149-54. PubMed abstract / Full Text

Nelson VS.
Durable medical equipment for children with spinal cord dysfunction: implications of age and level of injury.
J Spinal Cord Med. 2007;30 Suppl 1:S172-7. PubMed abstract / Full Text

Rodby-Bousquet E, Hägglund G.
Use of manual and powered wheelchair in children with cerebral palsy: a cross-sectional study.
BMC Pediatr. 2010;10:59. PubMed abstract / Full Text

Tefft D, Guerette P, Furumasu J.
The impact of early powered mobility on parental stress, negative emotions, and family social interactions.
Phys Occup Ther Pediatr. 2011;31(1):4-15. PubMed abstract

Authors & Reviewers

Initial publication: July 2008; last update/revision: January 2019

Current Authors and Reviewers:

Author:	Terry Holden, PT
Reviewers:	Tina Persels
	Amanda Butler, MS
	Jennifer Goldman-Luthy, MD, MRP, FAAP
	Nancy Murphy, MD, FAAP, FAAPMR
	Clint Gibson, RN, BSN, CCM