> **VHA PROSTHETIC CLINICAL MANAGEMENT PROGRAM (PCMP)**
>
> **CLINICAL PRACTICE RECOMMENDATIONS**
>
> **FOR PRESCRIPTION OF SEAT LIFT MECHANISMS**

# [BACKGROUND]{.underline}

> The Under Secretary for Health directed VHA's Prosthetic and Sensory
> Aids Service Strategic Healthcare Group to establish a Prosthetic
> Clinical Management Program (PCMP). The objectives are to coordinate
> the development of recommendations for prosthetic prescription
> practices and contracting opportunities to assure technology
> uniformity and ease of access to prosthetic prescriptions and patient
> care that will lead to valid outcome measures and analysis for
> research purposes.
>
> A workgroup with input from selected clinicians convened to recommend
> a policy regarding appropriate clinical recommendations for providing
> seat lifts through prosthetics for disabled veterans.
>
> Maintaining patient independence is an important consideration in
> providing any type of prosthetic item. Prosthetic items are issued in
> VHA solely on the basis of medical necessity. While the use of a seat
> lift might appear to be medically necessary to many patients, in many
> situations maximum function can be obtained through appropriate
> intervention with therapeutic exercises, or other more appropriate
> means. VA's purpose is not to provide a comfortable home environment,
> but rather to provide medically necessary intervention to increase
> functional independence.

# [POLICY]{.underline}

> The purpose of these clinical practice recommendations is to assist
> practitioners in clinical decision-making and to standardize and
> improve the quality of patient care. The prescription of a lift chair
> is not medically indicated, and for this reason, only the lift
> mechanism will be provided.

# [MEDICAL CRITERIA]{.underline}

> The basic purpose of any seat lift mechanism is to make transferring
> from a seated to a standing position easier by reducing the torque
> movement necessary about the hips and knees. This can be done through
> several parameters: by the use of downward pressure on the arms of a
> chair through the upper extremities, by increasing the height of the
> chair, and by altering the foot position. The veteran should supply
> the chair with arms, a standard household commodity, and the foot
> position can be altered as possible to increase the ease of the
> transfer. The seat lift mechanism addresses the last factor.
>
> What is the objective to be gained by increasing the ease of transfer
> from the seated to the standing position? The purpose is to increase
> the functional independence of the veteran by allowing him or her to
> come to standing independently. The functional reason for coming to
> standing independently is to ambulate independently. This, therefore,
> requires that the veteran be able to ambulate independent of a
> caregiver once standing, with or without ambulation assistive devices
> such as walkers or canes. In most homes, a distance of 20 feet would
> provide functional independence for recognized activities of daily
> living, such as feeding or toileting or hygiene.
>
> In order for VA to provide a veteran with a seat lift mechanism for
> home use, at least the following criteria must apply:
>
> 1\. The veteran must be interested in obtaining maximal independence
> in moving from a sitting position to a standing position. The patient
> must be willing to undergo a thorough examination to determine the
> etiology of the problem that prevents him/her from moving from sit to
> stand, and if amenable to therapeutic exercise or to other appropriate
> interventions, to follow and complete the prescribed program.
> Re-evaluation for the medical necessity for the seat lift would be
> necessary.
>
> 2\. The veteran must be able to ambulate independently with or without
> an assistive device once he/she comes to a standing position, for a
> distance of at least 20 feet.
>
> 3\. The veteran should have severe hip and/or knee joint arthritis, as
> noted on radiographic studies, or have severe hip extensor and/or knee
> or arm weakness due to an identifiable severe neuromuscular condition.

4.  The veteran is unable to arise from a standard hard seat straight

back chair with arms, due to the above neuromusculoskeletal
condition(s).

5.  The veteran must have the cognitive and physical ability to safely
    operate controls.

6.  In general, a seat lift mechanism would not be provided to:

    A.  An individual who is confined to a wheelchair and/or is unable
        to ambulate a distance of 20 feet.

> B. An individual who has severe balance deficits.
>
> C. An individual with significant cognitive deficits which
>
> would prevent the safe and proper operation of the seat lift.

7\. The physician ordering the seat lift mechanism must be the treating
physician or consulting physician for the disease or condition resulting
in the need for a seat lift. The physician's record must document that
all appropriate therapeutic modalities (e.g., medication, physical
therapy) have been tried and failed to enable the patient to transfer
from a chair to a standing position.

> **IV. [INDICATIONS/CONTRAINDICATIONS]{.underline}**

Indications for a seat lift mechanism include therefore, only the
following, given the above considerations:

-   Inability to come to standing independently, due to severe permanent
    weakness of hip or knee extensors not remediable by medical
    intervention, or

-   Inability to flex both knee joints to greater than 100 degrees due
    to severe arthritis, or

-   Oother joint problems, identifiable on radiographic films.

Contraindications to attempting to transfer from the seated to the
standing position independently:

-   Decreased cognitive status, such that safety precautions could not
    be observed, or the safe procedure could not be learned, or the
    mechanism involved could not be learned or remembered.

-   Weakness such that independent stance or ambulation to 20 feet or
    greater could not be performed. This voids any functional objective
    of independent standing.

-   Truncal weakness such that sitting balance cannot be maintained
    independently. This is a safety factor in the use of the lift.

# V. [REFERENCES]{.underline} {#v.-references .unnumbered}

> 1\. **"**Determinants of the Sit-to-Stand Movement: A Review." Manssen
> WGM, Bussman HBJ. Stam, HJ. Physical Therapy 2002;82:866-879.

APPROVED/DISAPPROVED:
\_\_\_**[SIGNED]{.underline}**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Jonathan B. Perlin, MD, PhD, MSHA, FACP

Acting Under Secretary for Heath

Date: \_\_[8/26/04]{.underline}\_\_