Multidisciplinary Team in Wheelchair Service Provision
Original Editor - Perth Rosen and Yasmin Garcia, from UCP Wheels for Humanity, as part of the Wheelchair Service Provision Content Development Project
- 1 Introduction
- 2 Multidisciplinary Approach to Wheelchair Provision
- 3 Referral
- 4 Assessment and Prescription
- 5 Product Preparation and Fitting
- 6 User and Caregiver Training
- 7 Follow Up, Repair, and Maintenance
- 8 Follow-Up Services Provided by Health and Rehabilitation Experts beyond Wheelchair Services
- 9 Wheelchair User’s Role in Service Delivery
- 10 Resources
- 11 References
When a person loses or is at risk to lose the ability to function, whether due to an injury, medical condition, chronic disease, or merely to the aging process, rehabilitation may be needed to regain these functions and enhance the individual’s independence. A variety of factors can influence the goals of rehabilitation, including the patient’s age and the roles, as well as cultural and environmental factors.  For instance, a child who was born with cerebral palsy may need physical, occupational, and speech therapy to reach the developmental milestones for children of his or her age. By contrast, an adult recovering from a long hospital stay may need respiratory therapy to improve respiratory capacity and physical therapy to strengthen leg muscles such that the individual is able to walk safely to work. Both the type and intensity of rehabilitation services required and the health and rehabilitation professionals needed to provide rehabilitation care differ depending on the individual.
Rehabilitation best practices call for a multidisciplinary team approach involving a group of professionals with complementary clinical knowledge, roles, and skills that can formulate and provide timely and effective interventions.  Members of a multidisciplinary team should complement each other’s roles to facilitate improved client care. An environment of mutual respect and support, shared responsibilities, and a problem-solving attitude are key elements in building a well-defined team around a common goal. 
Personal mobility has been recognized as a human right , and the ability to move independently in one’s environment has been established as a major goal of rehabilitation. Personal mobility does not refer merely to the ability to walk, but to the ability to move in the way and time one chooses.  As a result, wheelchair provision is an important aspect of rehabilitation services. An appropriate wheelchair not only enables a mobility-impaired person to get to the bathroom in his home, but to be more socially included in his community. It can also facilitate greater access to complimentary healthcare services that further reinforce rehabilitation goals.
For individuals with complex disabilities or functional limitations, a multidisciplinary teamwork approach may be especially important.  While a trained seating expert can treat certain elements of care alone, those with multiple healthcare needs or physical malformations often require support from a range of healthcare and rehabilitation professionals with complementary skills. 
Wheelchair provision recognizes the need for a diverse array of coordinated health and rehabilitation services ranging from a seating, positioning, and mobility assessment to complex orthopedic and neurologic interventions. Wheelchair and rehabilitation services can be provided in diverse settings and may follow different provision models depending on the local context, including the structure of the local health system and the availability of trained professionals. 
Multidisciplinary Approach to Wheelchair Provision
As discussed, at times a trained seating expert alone, such as a trained physical or occupational therapist, may be the most appropriate provider of a seating, positioning, and mobility intervention.  At other times, a multidisciplinary team comprised of therapists, physicians, physiatrists, orthopedic surgeons, urologists, dietitians, neurologists, orthotists and prosthetists, specialized nurses, rehabilitation engineers, wheelchair technicians, wheelchair suppliers, and social workers are needed to provide appropriate care. Wheelchair provision best practices call for close collaboration with the user as an important member of the team. 
A number of professional associations and international organizations provide guidelines on appropriate wheelchair-service provision. For instance, the Rehabilitation Engineering and Assistive Technology Society of North America’s (RESNA) Wheelchair Service Provision Guide  and the [http://www.who.int/disabilities/publications/technology/English Wheelchair Guidelines (EN for the web).pdf World Health Organization’s Guidelines on the Provision of Manual Wheelchairs in Less Resourced Settings]  outline a common set of wheelchair services (described below) needed to appropriately meet user needs and goals. Under this approach, the multidisciplinary team should work in a collaborative, coordinated, and harmonious fashion to complete the following tasks:
Depending on the local healthcare system, a healthcare or rehabilitation professional, social worker, or a non-health professional may refer the client to a wheelchair service provision center for an evaluation. In settings with more established wheelchair services, an authorized physician, such as a physiatrist, should refer the client to the wheelchair provider with a prescription.  A social worker may also arrange and coordinate a seating and mobility assessment with the respective clinical staff. Similarly, a physical or an occupational therapist could identify the need for a wheelchair and other medical equipment to increase function and independence in mobility-related activities of daily life (MRADLS), such as moving around the home to eat. In less resourced settings, where the provision of wheelchair services has not been formally established, a family member, caregiver, community health worker, or another wheelchair user could make the referral to the provision center. 
Assessment and PrescriptionAt least one trained seating and mobility expert is required to carry out the assessment and wheelchair-selection stage of the wheelchair-provision model, depending on the complexity of the individual’s impairment.  The expert is often a physical therapist, occupational therapist, or physiatrist trained in seating and mobility (each professional should refer to his or her own local certification requirements for providing rehab equipment recommendations e.g. the ATP and SMS Certifications from RESNA in the USA). In more complex situations, such as those involving users with challenging positioning needs, more than one expert may be needed in addition to a certified rehabilitation technology supplier.  In countries where the availability of these professionals is limited, a wheelchair provider with less training may independently supply basic mobility devices if they have the right training and skills (like the WHO WSTP Basic and Intermediate). In this case, clients with more complex needs should always be referred to the appropriate seating, positioning, and mobility experts.  In situations where a limited range of wheelchair products is available and the provision model does not impose a potential conflict of interest, the seating and mobility expert may also be trained in the technical aspects of supplying the products directly. 
The seating and mobility expert should:
- Identify the user’s goals and needs;
- Perform an initial interview requesting information on internal and external factors affecting the type of wheelchair provided, such as the individual’sphysical status and medical conditions, lifestyle, vocation, activities, living environment, and current or previous use of any mobility equipment;
- Evaluate body functions and structures
- Facilitate wheelchair trials and/or simulations (provided mostly in well-resourced settings);
- Explore funding sources for the wheelchair with the user;
- Make and discuss an evidence-based seating-and-mobility intervention plan with the user;
- Inform the user about wheelchair options2;
- Assist the user in selecting the final wheelchair2;
- Document the assessment process, detailing wheelchair recommendations, including type, size, special features, modifications, and user’s preferences;
- Identify the set of measures and/or indicators that will be used to evaluate the outcomes of the rehabilitation plan
The rehabilitation technology supplier should:
- Make wheelchair recommendations based on the seating and mobility expert’s evaluation; and
- Provide wheelchair for trials and simulations either at home or in the community or provision center2.
The wheelchair user should:
- Actively participate in the assessment, trial, and recommendation stages and provide requested information; and
- Make a decision regarding the type of wheelchair to use, as well as its components and configuration based on the seating and mobility expert’s guidance and the individual’s personal preferences. When a user is unable to articulate his or her needs due to age or cognitive or communication issues, a family member, relative, or caregiver should take on this role. 
Product Preparation and Fitting
The seating and mobility expert should:
- Place the wheelchair order, completing and submitting all required documentation according to locally established procedures;
- Indicate required product modifications and configurations to the wheelchair supplier or technician and answer all of their questions;
- Confirm that the wheelchair is ready and safe to be delivered to the user;
- Ensure that the wheelchair and its components fit the user appropriately to optimize functionality, comfort, and safety; and
- Document the fitting process, including the identification of any follow-up service and outcome measures. 
The rehab equipment supplier or wheelchair technician should:
- Assemble the wheelchair and prepare it according to the seating and mobility expert’s specifications;
- Perform any required modifications;
- Build/provide individualized postural support components;
- Verify that the wheelchair is ready and safe to deliver to the user;
- Communicate with the seating and mobility expert to resolve any issues;
- Assist the seating and mobility expert with product fitting and delivery if needed.
User and Caregiver TrainingUsers must be trained on how to maintain, handle, and move around in their wheelchairs in order to maximize the wheelchair’s benefit.  Proper training has been shown to be an important differentiator between independent and dependent mobility.  This includes the provision of basic healthcare advice, especially on how to avoid pressure sores or any further deformities or complications from use of the wheelchair. 
A seating and mobility expert should:
- Provide information and training to the user and their caregiver on how to handle the wheelchair, perform basic wheelchair skills, and ensure skin integrity;
- Refer the user to peer-training groups for high-level wheelchair skills;
- Provide information on other available resources; and
- Document training needs and outcome measures.
A wheelchair user taking on the role of service provider could also provide the training and advice indicated above. 
The rehab equipment supplier or technician should:
- Provide training on how to maintain the wheelchair and perform basic repairs, as well as information on other locally-available maintenance/repair services; and
- Provide training on the wheelchair’s specific functions or operations.
Link to other Wheelchair Skills Training sources.
Follow Up, Repair, and MaintenanceFollow-up clinical and technical support should be made available to all users to ensure that their wheelchairs continue to be appropriate for their needs. Providers should arrange, coordinate, and/or refer the user to other healthcare and rehabilitation specialists as needed, and further user training and maintenance and repair support should be made available.
The seating and mobility expert should:
- Assess the wheelchair’s fit and functionality;
- Provide additional training;
- Provide more intensive follow-up for at-risk clients, or those with changing needs;
- Refer the user to other healthcare professionals as deemed appropriate;
- Document service provision and evaluate outcomes; and
- Reassess the user to begin the wheelchair provision process again if needed.
The rehab equipment supplier or wheelchair technician should:
- Adjust the wheelchair as needed to better fit the user;
- Perform additional wheelchair modifications as requested;
- Provide maintenance service;
- Make repairs and solve other technical problems; and
- Assist in reassessing users for new wheelchairs and providing wheelchair recommendations as needed.
Follow-Up Services Provided by Health and Rehabilitation Experts beyond Wheelchair Services
If the wheelchair user presents with incontinence issues, he or she should be referred to the proper specialist as incontinence can place the user at risk for the development of a pressure sore.  The most appropriate professional to provide guidance on managing bladder issues is a urologist. The urologist should assess the user and provide him or her with an appropriate treatment and management plan for the incontinence issues. The goal of bladder management is to achieve and maintain a functional bladder-drainage mechanism and prevent infections of the genitourinary system.  For more information in this topic refer to the Consortium for Spinal Cord Medicine’s Clinical Practice Guideline: Bladder Management for Adults with Spinal Cord Injury.
If the wheelchair user presents with neurogenic bowel problems, he or she may be at risk for pressure sores, unplanned bowel movements at socially inappropriate times and places, infections, and other bowel problems such as constipation, diarrhea, among others.  Therefore, the user should be referred to a specialist, in this case a gastroenterologist, to assess the type of neurogenic bowel issue the user is facing and provide the bowel emptying program most appropriate to the user’s needs. The intervention of a nutritionist and an occupational therapist is also recommended to balance the user’s amount of fluid and fiber intake, and to assess function to properly complete bowel care.  For more information in this topic refer to the Consortium for Spinal Cord Medicine’s Clinical Practice Guideline: Neurogenic Bowel
Management in Adults with Spinal Cord Injury
Pressure-Sore Management and Prevention
Pressure sores can be a life-threatening problem.  There are many physical factors that can lead to the development of a pressure sore, including a diminished ability to move or change position, incontinence, orthopedic deformities or asymmetrical body position, and contractures.  Other systemic factors affecting the physiology of the tissue and its ability to heal may also exacerbate the risk of skin breakdowns such as bad nutrition, a previous history of pressure sores, advanced age, and decreased sensation.  As multiple factors can contribute to a pressure sore, a multidisciplinary team approach involving a wide range of specialists is often essential to its management. For instance, a nurse specializing in wound care should focus on a treatment plan that helps to heal an open wound, avoid infections, and promote tissue repair; a nutritionist should promote a diet rich in proteins and monitor the patient’s body weight; a trained seating and positioning expert, such as a physical or occupational therapist, should focus on pressure distribution, promotion of symmetrical seating positions, prevention of awkward body positions, reduction of shear and friction forces, and pressure relief techniques; an incontinence management specialist should establish a bladder management program; and an orthopedist should focus on the prevention and amelioration of orthopedic deformities that can cause high pressure points, bad body position, and limited range of motion in the joints. 
Generally speaking, the collaborative activities of a multidisciplinary team should include: (i) identifying and addressing the risk factors for pressure ulcers; (ii) establishing a prevention program and treatment; and (iii) educating users about how to inspect and care for the skin and prevent skin breakdown.  For more information in this topic refer to the Consortium for Spinal Cord Medicine’s Clinical Practice Guideline: Pressure Ulcer Prevention and Treatment following Spinal Cord Injury and the National Pressure Ulcer Advisory Panel’s Quick Reference Guide on the Prevention and Treatment of Pressure Ulcers.
Psychosocial factors such as self-esteem, motivation to use technology, emotional status, coping strategies, current age and age at disability onset, and social stereotypes, among others, can influence wheelchair use.  A person with a psychosocial issue may be more reluctant to use a wheelchair. In cases such as these, the user would likely benefit from a referral for psychological support or peer counseling.
Physical and Occupational Therapy
Physical and occupational therapists play an important role within the rehabilitation team as they can assist wheelchair users to maintain or further develop their physical condition to prevent secondary injuries, increase function, avoid contractures, and preserve upper extremity function; and learn new propulsion, transfer, and pressure-relieving techniques. Therapists can also instruct family members and other caregivers on appropriate techniques to for wheelchair pushing and assisted transfers.
The presence of spasticity in users may interfere with their range of movement, sitting posture, daily activities, as well as ability to move independently and interact socially. It may also be a risk factor for the development of pressure ulcers and body deformities.  A multidisciplinary approach should be taken to treat the spasticity involving the participation of physical therapists to promote movement and maintain muscle length; occupational therapists to maintain function and range of movement in upper-extremity joints and monitor posture and positioning; and doctors to provide pharmaceutical treatment, such as botulinum toxin or intrathecal baclofen and phenol. 
Wheelchair User’s Role in Service Delivery
- Experienced wheelchair users often know what will be “an appropriate wheelchair” for them.
- If they have used a wheelchair already, they will have ideas about what works for them, and what they would like to change.
- Wheelchair users who have not used a wheelchair before will need more information.
- Wheelchair user should be an equal participant on the wheelchair seating team.
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