New options in mobility aids – includes related articles
Nearly every mobility aid, from canes to wheelchairs, has been undergoing dramatic revolution. The old models are still around, but they are now joined by new ones sporting bright colors, new materials, and state-of-the-art electronics.
With the new models has come a new approach to their use. Today the medical profession is convinced that without proper training, mobility aids – even that simple cane – may fall short of their potential and even cause harm.
“Many people believe if you need an aid, you just call up your nearest medical supply house and order what you need,” said Dr. Catherine W. Britell, a physiatrist with many MS patients, who practices in Seattle. “It’s not that easy.” Neither are the psychological issues a person must sort through, as nearly every user will say. “Keep in mind that the truly civilized person uses tools,” Dr. Britell reminds her patients. Mobility tools provide basic transportation, conserve energy, and protect joints from injury. And there are a lot of options to choose from.
“Some people with MS who can walk quite well get fatigued easily. So they need to decide how to best use their limited walking energy each day,” Dr. Britell said. Evaluation as well as training often results in mixed or intermittent use of a group of aids.
As an example, she recalled the case of a physician with MS who needed help in carrying on his demanding professional life: “He had fairly good balance but was hampered by a left-sided weakness and spasticity,” she said. “Despite his adequate balance, he had trouble walking and a tendency to stumble over rugs. He tired easily because his toe tended to drop and spasticity pulled his foot in and down. His left hand was also weak and spastic. He explained to us that he had to make hospital rounds and do other tasks that required good mobility. At the time, he was driving a sports car mith no special adaptations except for an automatic transmission.
“The first thing we did was to see how we could make his walking better,” Dr. Britell explained. “We decided initially to try a prefabricated brace inside his shoe. But the brace pushed his knee forward when he lifted his foot, which caused his leg to buckle.
“But we found that by positioning his foot well, we could decrease his spasticity. So we made him a shoe insert, not a brace, that kept his toes spread. This significantly decreased his spasticity and improved his gait. We also gave him a good arch support. These aids helped him avoid tripping.
“Next we prescribed a cane for added stability. He decided on a very narrow-based quad cane, the kind with four little legs. He liked this because he could leave it standing up by itself, and didn’t have to worry about it clattering to the floor.”
These new aids gave him short-distance mobility, but he also needed some kind of wheeled mobility aid, Dr. Britell said.
“With his fatigue level and hand weakness, we didn’t want to get him a manual wheelchair. We suggested a number of options, and he ended up choosing a battery-powered chair that could be disassembled fairly easily for transport. Later he stopped using his car and purchased a van to accommodate his chair.
“If some professional had simply told this doctor that he needed all these things – a brace, a quad cane, and wheelchair – he might well have balked and said, ‘Hogwash – I’ll just walk.’ He found a solution by being given the opportunity to try out various options.”
Such combination solutions are becoming common. Dorothy Boone Kidney, a writer with MS, explains how she combines methods:
“I still walk very well with a wheeled walker within my house and for short distances outside. The walker folds up and fits in the back seat of my car for short excursions. For longer trips, I use my electric scooter, which I keep in the trunk.
“At this point in my situation,” Ms. Boone Kidney explained, “I feel that the flexibility, mobility, and ease that I experience in using my walker, as well as the exercise I obtain from it, are beneficial to my health. If, however, I reach a place where I think the walker is wearing me out, then I will certainly switch to a wheelchair.”
Mobility aids start with simple shoe inserts to reduce spasticity, as well as a variety of braces. Canes come with one or four legs; crutches as singles or doubles. Lofstrand or Canadian crutches have forearm cuffs for added support. Walkers are made in different weights and some have wheels. Wheelchairs can be manually operated or battery-powered and they are individually tailored to the size and the needs of the individual. New lightweight models weigh in at twenty to twenty-five pounds instead of forty, and, yes, they come in a variety of colors.
Through the miniaturization of electronies, a powered chair can be fully maneuvered and adjusted with sip-and-puff controls – no arm or hand use is needed – but these high-tech devices may cost from $20,000 to $30,000.
Finally there are the electric scooters with either three or four wheels. They, too, come in a variety of styles and colors. Some are mainly for indoor use while others can negotiate outdoor terrain. Scooter vehicles are popular because they look sporty rather than medical. Family members have been known to borrow these handy vehicles to zip around the house when their owners don’t need them.
“You can probably walk into a medical supply store and come out with one of these aids,” Dr. Britell said, “but it possibly won’t be the right choice for you. While reputable companies have knowledgeable technicians, we strongly advise people with MS to work with rehabilitation professionals who really understand the complex neuromuscular, biomechanical, functional, and psychosocial issues that affect decisions about mobility aids.”
Mary Holzer-doerr, an occupational therapist at the Burke Rehabilitation Hospital in White Plains, N.Y., agrees. “Training – which may be just a session or two – is essential. Many doctors are aware of the variety of mobility aids,” Ms. Holzer-Doerr continued, “but most of them are not really trained in how to use them.”
Physical therapist Surinder Brar, director of clinical services at the Tustin Rehabilitation Hospital in Tustin, California, starts her clients with a gait evaluation, which also typically examines the individual for related conditions such as weakness, balance problems, and spasticity. One big advantage of an evaluation is that it may determine that a mobility aid is not needed. For some people, the prescription may be specific physical therapy geared towards their walking.
If a mobility aid is needed, training is absolutely necessary to make sure a patient is using the mobility aid correctly, said Ms. Brar. “Many people think you should use a cane on your weaker side whereas, in most cases, you should use it opposite the weaker leg to provide increased support for that leg. Moreover, the improper use of axillary crutches may cause nerve damage in the arms.”
The not-insignificant issue
While canes and walkers may not present insurmountable financial obstacles, scooters and high-tech wheelchairs can, as noted, cost thousands.
Experts caution that insurance policies differ, but generally insurance coverage hinges on whether the aid is perceived as a medical necessity. Forest Jarnagin, a physical therapist at Health South Rehabilitation Hospital in Albuquerque, New Mexico, says that generally, 80 pereent of lower-priced items are covered, while buyers of the more expensive aids may get a 20 percent reimbursement.
“Unfortunately,” he said, “many of the government programs rate what we might consider necessities as luxuries. If you can walk at all, even ten feet with a walker, Medicare won’t buy you a wheelchair, even if ten feet is as far as you can walk at any one time.”
Steven Mendelsohn, author of the highly recommended book Tax Options and Strategies for People with Disabilities, says a rule of thumb is that if the aid you want is used in a hospital or if it is something that doctors historically have provided, it will probably be covered.
This means that higher-tech, more expensive devices are less likely to be reimbursable. “It’s unfikely that a state would require basic health insurance coverage to extend to powered mobility aids,” he said. “If an individual insurance policy were to cover them, it is most likely that it would do so under the heading of ‘durable medical equipment’.”
The issue of tax deductions for mobility aids is even more complicated than insurance reimbursement. You may only deduct the medical expenses that exceed 7.5 percent of your adjusted gross income. Therefore, if you anticipate several expenses, they should be lumped together in one year if possible. Mendelsohn says tax deductions are possible in these categories:
* Medical expense deduction: The test is the extent to which the mobility aid helps to mitigate the functional effects of a disability.
* Impairment-related work-expense deduction: If a mobility aid is used mainly to enable you to work, it’s deductible. If it’s something that you would have used whether you work or not, the IRS might perceive the device as inherently personal and disallow the deduction.
* Disabled access credit: Small businesses can take a yearly credit for expenses they incur to comply with the Americans with Disabilities Act. After the first $250 expense, they may claim 50 percent of all remaining expenses up to $10,000. These expenses would include mobility devices that would allow disabled employees to perform theirjobs.
For a more detailed discussion of these points, see Mendelsohn’s book, published by Demos Publications, $19.95. (To order, call 1-800-532-8663.) You might also call your local NMSS chapter for referral to a knowledgeable expert in your neighborhood.
COPYRIGHT 1994 National Multiple Sclerosis Society
COPYRIGHT 2004 Gale Group