November 24, 2009 To Whom It May Concern: Jonathan is a 13-year-old boy with progressive muscular weakness due to Duchenne Muscular Dystrophy (DMD). He is being followed by the Pediatric Neuromuscular Center at “ABC” Rehab. His most recent evaluation was on 10/27/09. He presents with weakness in all four limbs and is wheelchair bound. Jonathan has plantar flexion contractures bilaterally and moderate hamstring tightness. He wears recently made custom molded AFOs which he wears for about 2-3 hours per day when using a stander. He is able to feed himself, brush his teeth, and perform upper body dressing independently but requires assistance to perform lower body dressing. He is dependent with transfers and has a Hoyer lift he uses at home. He relies on a power wheelchair for mobility. He is no longer able to walk, despite the use of a walker and bilateral AFOs. He is unable to manage a rolling walker, cane or other assistive devices due to his arm weakness even with assistance from his caregivers. He has a back-up manual wheelchair, however he now has difficulty self propel his manual wheelchair short distances at home secondary to decreased endurance and strength. He has a paraprofessional throughout the day in school but remains in the power wheelchair throughout the school day. He now needs modifications to his current power wheelchair. Jonathan is currently 56.7 inches and 141 lbs. he is currently using an Invacare Storm TDX power wheelchair that he has had for 2.5 years which needs modifications and adjustments to fit him properly and promote optimal alignment. Jonathan is wheelchair bound and he uses it independently in school and outdoors. He received his power wheelchair 2.5 years ago from RRT which is no longer in business. His weight has increased since he’s been on Prednisone and his power wheelchair needs to be grown. Upon evaluation, his chest strap is no longer long enough, the hip abductor pads are pushing into the sides of his legs and his calves are pushing into the swing-away portion of the footrests increasing his risk for pressure sores and injury. Jonathan was measures and now requires a 20x22 wide chair. He currently sits in 15x15 size chair. Power tilt will be added to his power wheelchair to assist with pressure relief and repositioning. He will be getting a new chest strap and new headrest for when he goes into tilt. His footrests will be adjusted for comfort once sitting. He will require a new back insert and cushion. He has mobility limitations that impair his ability to participate in mobility related activities of daily living (MRADL) that couldn’t be sufficiently and safely resolved by the use of a cane or walker. Modifications made to his power wheelchair are requires for Jonathan to use it in the home and community setting. The length of needs for these modifications to his power wheelchair is for lifetime. He is currently using an Invacare power wheelchair that he has had for 2.5 years which needs modifications and adjustments to fit him properly and promote optimal alignment: Invacare receivers for existing footrests: The receivers are requires so the footrests can be attached to the top system. BioDynamics Solid back insert, linear, with 1.5” foam with adjustable lateral trunk supports: A posterior positioning back is requires to correct and accommodate the postural asymmetries of the thoracic and lumbar spice which result from muscle weakness, poor motor control and impaired balance due to the diagnosis of DMD. Adjustable lateral trunk supports are requires to prevent lateral flexion and to promote proper seating alignment. They are requires because of Jonathan’s decreased trunk tone and control. Removable lateral thoracic support brackets are required to allow removal of the support pads for safe transfers, personal care, repositioning and functional activities. Lower-level, less expensive backs won’t suffice and meet the requirements of Jonathan’s positional needs. BioDynamics positioning cushion to attach to seat pan, vinyl cover; with 3” growth tall: Jonathan is unable to carry out a functional weight shift due to his diagnosis of DMD. He will be confined to his wheelchair fore more than 6 continuous hours on a daily basis when at school. He has significant postural asymmetries due to his diagnosis of DMD and is unable to perform an adequate weight shift secondary to his weakness. He requires a seat cushion with sufficient pressure-relieving capabilities to maintain intact skin integrity and to allow for functional sitting tolerance. This cushion provides the proper combination of pressure relief and positional support necessary for him in his power wheelchair. Lower-level, less expensive cushions won’t suffice and meet the requirements of Jonathan’s positional needs. 1 pair hip guides; BioDynamics adjustable via back insert: This is required to prevent Jonathan’s legs from abducting to a position wider than the wheelchair and will maintain him in proper hip alignment while operating the wheelchair. 1 pair lateral knee supports BioDynamics, removable: This is required to prevent Jonathan’s thighs from abducting to a position wider than the wheelchair and will maintain him in proper alignment while operating the wheelchair. This will prevent his lower extremities (calves) from resting on the swing-away function of the swing-away leg rests and will prevent injury and pressure sores. BioDynamics Chest Belt, Velcro across lateral supports with pad in center 8”x3”: This type of belt is requires for safety when being transported in the school bus to/from school. Also, it provides input to the anterior torso to maintain an upright position. The belt will maintain proper positioning while seated in the wheelchair. BioDynamics headrest with detachable hardware: A headrest is needed to support Jonathan’s head in optimal position. He is unable to maintain an upright, middling head and neck position due to muscle weakness, poor motor control and poor sitting balance. Removable headrest brackets are required to allow removal of the support pads for safe transfers, personal care, and repositioning and functional activities. It is medically necessary for Jonathan to receive these modifications to his current power wheelchair to support his needs to improve alignment, slow progression of further
deformity and provide total body comfort to increase sitting tolerance. He requires these modifications to assist and support his needs in the home and community and to prevent fatigue so he can actively participate. Jonathan has the functional ability to use his drive controls and has adequate cognition, visual ability and judgment necessary to safely operate his power wheelchair independently. He uses a standard joystick that must be positioned functionally to operate the wheelchair independently. His home is already wheelchair accessible and there is accessible transportation available to his family. If Jonathan does not receive these modifications to his current power wheelchair, the medical consequences include a loss of function, discomfort leading to reduced sitting tolerance, increased pressure, and reduced participation and socialization. Anything you can do to ensure that Jonathan receives this very necessary equipment would be greatly appreciated. Please do not hesitate to contact us with questions or comments at 555-555- 5555. Sincerely, **Modification**
January 07, 2010 To Whom It May Concern: I am writing to provide an addendum to Jonathan’s letter of justification for his power wheelchair modifications: 1 pair lateral knee supports, BioDynamics, removable: This is required to prevent Jonathan’s thighs from abducting to a position wider than the wheelchair and will maintain him in proper alignment while operating the wheelchair. This will prevent his lower extremities (calves) from resting on the swing-away function of the swing-away leg rests and will prevent injury and pressure sores. They are requires to be removable for safe and easy transfers. Without the quick release hardware, Jonathan would be at risk for hitting the lateral knee supports when transferring in and out of the wheelchair making him at risk for injury. Sincerely,
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