Wheelchairs and Adapted Strollers

What you should know about wheelchairs and adapted strollers - Mobility is very important to all of us. Children who cannot walk on their own need opportunities to move, even if assisted by other people or equipment, to maximize their cognitive and social development. Children are naturally curious and want to explore their environment. Wheelchairs may allow children to participate with their peers in community settings, thereby promoting function and independence. They conserve energy for children who may struggle to ambulate over longer distances, and reduce the risk of caregiver injuries related to carrying their children. For smaller children, strollers may be an appropriate alternative to a wheelchair, and are more easily transported in standard cars than 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 alternative to wheelchairs, and are often preferred by families because they can be easily loaded and unloaded from vehicles. Strollers tend to fit in places where wheelchairs may not, for instance in narrow doorways and hallways. Strollers differ from wheelchairs in that they provide a more flexible than rigid seating position, increasing sacral pressure. Additionally, children generally need caregivers to push their strollers, whereas children may learn to navigate manual or power wheelchairs independently. Specialized strollers can be designed and ordered through a seating clinic much like a wheelchair, or families may consider purchasing a stroller and adapting to their own needs with extra storage, straps and padding. However, it is important to know that insurance typically only covers EITHER a stroller OR a wheelchair in a five year period. If both a stroller and wheelchair are indicated, then it may be necessary to pay for one out of pocket, and generally strollers are less expensive than wheelchairs.

For more indepth information 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.

The First Wheelchair – Most children walk by 18 months of age. If a child does not have independent mobility by then, it is time to discuss mobility options, such as wheelchairs. Some children with significant 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."

The process of obtaining a wheelchair can be exciting and overwhelming, both emotionally and financially. It can sometimes trigger painful emotions that you may not expect. These may relate to accepting a diagnosis or a degree of permanence of disability, or that the disability will now be obvious to others, or the need to implement changes in housing or lifestyles. Anticipating these feelings and working through them is essential.

First Step – Find a Physical or Occupational Therapist with seating and positioning experience (see Resources>Services below). If the child already receives physical or occupational therapy services through Early Intervention, school, or privately, and has a therapist with experience in wheelchairs, this is a perfect fit since he/she already knows the child and family. Some therapists and vendors have RESNA certification (ATP, SMS, RET) in assistive technology and seating and mobility. This certification promotes a standard of professional practice in the field. A physician may write two orders/prescriptions, one for a wheelchair (or other assisted mobility device), and another for the physical or occupational therapist or seating clinic to evaluate the child for a wheelchair and generate a detailed prescription of the most appropriate device for the child. See Sample Physician Order for Wheelchair or Adapted Stroller and Seating Evaluation ( PDF Document

107 KB).

The Assessment – A team evaluation is recommended. All team members work closely together and make a unique contribution. Team members may include, but are not limited to:

The consumer and/or family members drive the team with their unique insights into what may work, what has been previously tried, and can identify their needs for assistance with mobility. Ultimately, the decisions are theirs!
Occupational or Physical Therapist (OT/PT) will evaluate fine motor (hand), gross motor (total body), touch, and movement abilities; 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 environment for access (home, car, school, etc.). Therapists will also instruct parents/caregivers in the use of the wheelchair, how to assemble/disassemble the wheelchair for transportation, how to get the child in/out of the wheelchair, and set up training opportunities to allow the child to become as independent as possible.
Speech Therapist will evaluate the child's communication abilities – is an augmentative communication device needed? If so, how will it be used in the wheelchair?
Rehabilitation Engineers write prescriptions for the assessment, the wheelchair, and ancillary equipment. These are generally based on (or just co-signatures of) recommendations from the PT/OT. Sometimes referrals are needed to facilitate 3rd party payment. The physician should communicate any special medical needs to be considered. It may be appropriate to rent a wheelchair when the disability is expected to be temporary, such as following a surgery or injury. Physicians can guide decisions regarding the need for ventilator trays, and adaptations for transporting oxygen, suction and feeding supplies on the wheelchair. Often a co-signature on the letter of medical necessity (LMN) completed by the therapist is required.
Teachers, rehabilitation counselors, employers, day care providers, respiratory therapists, recreational therapists, nurses, orthotists, friends, architects, etc. can also make valuable team members to guide practical and usability decisions and to assist in devising accommodations at home, school, and elsewhere.
Wheelchair/Seating Vendor's representative will submit all the finished paperwork to Medicaid or other insurance. They will obtain prior approval, order equipment, assemble, and deliver it. Wheelchair vendors are often certified seating specialists and have valuable product information and expertise. They can explain the pros/cons of each type of wheelchair to the parents and team. They can also provide price quotes and cost ranges. Vendors have a repair shop where flat tires and other repairs can be made.

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.

Process – Following the assessment, a letter of medical necessity is written (usually by the PT or OT) to justify the medical necessity for the wheelchair. It must be co-signed by the physician, or a prescription must accompany the letter. This is submitted by the vendor to Medicaid/insurance for prior approval. Once approval has been received, the equipment is ordered. When the equipment is received, a final wheelchair assessment by the team is scheduled to ensure an appropriate fit. This process generally takes about 3 months. If the wheelchair is denied by Medicaid/insurance, the decision can be appealed. Appeals must be done in a timely fashion. Check the denial letter for specific timelines. See the Writing Letters of Medical Necessity (general) Issue page and Resources>Services below for assistance in appealing.

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 or 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 not uncommon 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. See the How to Know If a Wheelchair Fits Issue page. Medical needs, function, and preferences change with time also and each should be continually addressed. Repairs may also be needed.

Special Considerations – Some children require special adaptations for their wheelchair such as integrated communication devices or adaptive controls. The team of specialists involved in developing the child’s chair usually can give advice about special seats and other adaptations to make the chair work well for the child and his/her family or caregivers. The care team including the family, therapists, educators, and prescribing physician can work together to ensure that the child’s seating needs are met comprehensively.

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 Professionals

Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)
RESNA is an interdisciplinary association of people with a common interest in technology and disability. RESNA website includes a national certified AT professionals locator, provides assistive technology standards; organization publishes a journal and offers a credentialing program.

RESNA Position Papers
A RESNA Position Paper on Clinical Practice is an official statement by the organization that, based on the consensus of experts and evidence summarizes current research and best-practice trends in relevant areas of Assistive Technology. These Position Papers on Clinical Practice, issued by the international professional organization, declare the necessity (medical and/or functional) of specific assistive technology devices and services under appropriate circumstances, and guide practitioners in decision making.

For Parents and Patients

Easter Seals Easy Access Housing Program
Here you will find helpful educational brochures and an expert panel with additional resources and easy-to-implement tips for making an accessible home a reality.

Adaptivemall.com
A commercial site offering a variety of assistive technology products.

Rifton
A commercial site offering a variety of assistive technology products

AbleData.com
ABLEDATA's primary mission is to provide objective information on assistive technology and rehabilitation equipment available from domestic and international sources to consumers, organizations, professionals, and caregivers within the United States. The site is sponsored by the National Institute on Disability and Rehabilitation Research (NIDRR), which is part of the Office of Special Education and Rehabilitative Services (OSERS) of the U.S. Department of Education.

KSL.com
A commercial on-line resource for resale items, including medical equipment, strollers and wheelchairs, and wheelchair-accessible vehicles.

Craigslist
A commercial on-line resource for resale items including medical equipment, strollers and wheelchairs, and wheelchair-accessible vehicles. Search by city.

Services

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 (13) 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: April 2013

Current Authors and Reviewers (click on name for bio):

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

Authoring history

(Limited detail is available on authoring dates before 2014.)

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

Resources

Information & Support

For Professionals

For Parents and Patients

Services

Adolescent Health Transition Programs

Assistive Technology Equipment

CSHCN Clinics

Durable Medical Equipment

Legal Services, General

Local Support Groups, Disability/Diag

Occupational Therapy, Pediatric

Physical Therapy

Speech - Language Pathologists

State Institutions for Individuals with Disabilities

Helpful Articles

Authors & Reviewers