Spotlight on CELA: 'We have to advocate the data'


Simon Margolis at NRRTS sent out a bulletin this week announcing the clinical guest speaker at CELA 2011: Jean Minkel. Here's a Q&A with Minkel that will appear in the November issue of HME News.

Physical therapist Jean Minkel says CMS can’t have it both ways. If clinicians can provide evidence that manual wheelchairs, used over time, can result in injuries—and they can, she says—the agency needs to open up its wallet for power wheelchairs, sometimes both. Here’s what Minkel, an independent contractor working with a nonprofit agency called Independent Care System (ICS) and the featured clinical speaker at CELA in February, told HME News about comparing wheelchairs to shoes.

HME News: You work with adults at ICS, so you see what happens when a person doesn’t get the right wheelchair early on in life.

Jean Minkel: The information regarding aging with a disability should be influencing our practices today to make an impact on the next generation of wheelchair riders. I love the expression “the genius of and” as opposed to “the tyranny of or.” We need to think in a big picture way about how many young people could really benefit from a power chair and a manual chair. A power chair is more about efficient, long-distance, get-where-you-need-to-go-in-as-timely-a-fashion and a manual chair is about access and/or exercise. It’s two sets of shoes for two separate purposes.

HME: What does the evidence say about using manual wheelchairs over an extended period of time?

Minkel: There’s an abundance of evidence that increased force and increased repetition from pushing a manual wheelchair, from doing push-up pressure relief, from just reaching over your head—all of these activities have a cumulative effect that results in carpal tunnel, rotator cuff problems and even some elbow bursitis problems.

HME: What’s the prevalence of this happening?

Minkel: The Paralyzed Veterans of America clinical practice guidelines for preservation of upper extremity is a peer-reviewed, literature-backed document that goes through the evidence of shoulder pain in 70% of manual wheelchair riders after more than five years of propelling. The proof is there.

HME: Having both a manual and power wheelchair or transitioning to a power wheelchair earlier on in life sounds great, but is it realistic from a funding perspective?

Minkel: It’s not fair to say, “There’s no funding for that.” We have to professionally advocate the data. We can’t just say, “Hey, this is a good idea, because this is a cool, new chair.” You can get a $15 piece of foam at Michael’s, but it’s going to bottom out and you’re going to have really high interface pressures. That’s why I need a high-end, matrix-molded foam cushion to distribute pressure to prevent sores. We need to apply the same clinical evidence to justify an efficient mobility system, whether it’s manual or power.

HME: Are there also alternative sources of funding?

Minkel: I do think there needs to be a certain amount of creativity. If you have a 12-year-old child, do you really want to replace the manual chair with another manual chair or is this a chance to use the manual chair as a back up and introduce power and kind of alternate chairs? Also, are there other resources? If insurance pays for a power chair, are there resources to pay for the manual? I think all too often we don’t include people in resource allocation when we make those decisions.

HME: Do you work with providers who are hesitant to provide what you recommend because of difficulties with funding?

Minkel: As a clinician who writes her own letters and produces the evidence, I’m willing to go to bat. Every provider I work with knows I go to bat, and I’m going to go to bat all the way to the very end. It’s using evidence and being willing to, professionally, invest the time. So no, my providers don’t push back. I won’t tell you that it’s not time consuming, but I’ll also tell you that I can sleep well at night knowing that I’ve done the best I can do. Too often, I think, when an uninformed clinician who only relies on the feedback of some, but not all, suppliers, the response is, “Well that’s not covered.” They’re not given permission to say, “Well, let’s give it a try.”

Liz Beaulieu