What is the best approach for a physical and occupational needs assessment for a wheelchair-bound patient with Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)?

Physical and Occupational Needs Assessment for Wheelchair-Bound CIDP Patients

Wheelchair-bound patients with CIDP require a comprehensive multidisciplinary assessment conducted by physical and occupational therapists to evaluate positioning needs, mobility capabilities, transfer ability, pressure ulcer risk, and functional limitations, with serial reassessment every 3-6 months due to the fluctuating nature of CIDP. 1, 2

Immediate Assessment Priorities

Functional Status Evaluation

• Document ambulatory status and safety, including whether the patient is completely nonambulatory, has severely limited walking ability, or cannot accomplish mobility-related activities of daily living (ADLs) without a wheelchair 1
• Grade muscle strength using the Medical Research Council scale in neck, arms, and legs to establish baseline and track progression 2
• Assess upper body strength and coordination for self-propulsion capability, as this determines whether manual versus power wheelchair is appropriate 1
• Evaluate transfer ability (bed-to-chair, chair-to-toilet, car transfers) to determine need for assistive devices or caregiver assistance 1

Physical Therapy Assessment Components

• Perform serial pulmonary function testing including vital capacity and negative inspiratory force, as respiratory muscle weakness can develop in CIDP 2
• Test swallowing and coughing ability to identify aspiration risk, particularly if cranial nerve involvement is present 2
• Assess for facial weakness and ophthalmoplegia, as cranial nerve involvement occurs in CIDP variants 2
• Evaluate gait patterns (if any residual walking ability exists) using gait analysis systems to diagnose pressure areas and walking patterns 3

Occupational Therapy Assessment Components

• Assess activities of daily living (ADL) capacity: bathing, dressing, feeding, toileting, household mobility 3
• Evaluate instrumental ADLs (IADL): meal preparation, medication management, financial decisions, home safety, ability to live alone 3
• Screen for cognitive impairment that may impact safety and independence, as psychological symptoms are common in chronic neurological conditions 3
• Assess pain levels and characteristics (neuropathic, muscular, or radicular), as pain affects two-thirds of patients with inflammatory neuropathies and impacts rehabilitation participation 3, 2

Seating and Positioning Requirements

Pressure Ulcer Risk Assessment

• Evaluate for existing skin breakdown and pressure ulcer risk, particularly over bony prominences 1
• Assess need for specialized cushions based on sitting tolerance, weight distribution, and skin integrity 1
• Determine trunk support requirements based on core strength and sitting balance 1
• Consider power positioning features (tilt, recline) for patients unable to perform independent pressure relief 1

Wheelchair Specification Needs

• Manual wheelchair considerations: Requires sufficient upper body strength for self-propulsion; assess shoulder, elbow, and wrist function 1
• Power wheelchair indications: Indicated when patients lack upper body strength/coordination for manual propulsion or have rapidly fluctuating disease requiring energy conservation 1
• Environmental assessment: Evaluate home layout, doorway widths, flooring surfaces, ramps, and community access needs 1

Monitoring and Reassessment Schedule

Serial Evaluation Requirements

• Reassess every 3-6 months for patients on maintenance immunotherapy, as CIDP has a fluctuating course with potential for treatment-related fluctuations occurring in 6-10% of patients 2, 4
• Perform longitudinal mobility assessment as disease-related factors such as contractures can change mobility over time 3
• Monitor for treatment response: 75% of motor CIDP patients respond to IVIG, and functional status may improve with optimized therapy 5
• Watch for disease progression: Approximately 5% of patients develop acute-onset CIDP with repeated relapses requiring treatment adjustment 2, 4

Multidisciplinary Team Coordination

Essential Team Members

• Physical therapist: Conducts mobility assessment, develops exercise program, evaluates need for walking aids 3, 1
• Occupational therapist: Assesses ADL/IADL capacity, recommends adaptive equipment, evaluates home safety 3, 1
• Neurologist: Manages underlying CIDP treatment, as optimization of immunotherapy may improve functional status 2, 6
• Rehabilitation specialist: Coordinates comprehensive rehabilitation program including range-of-motion exercises, strength training, and functional training 2
• Speech therapist: Evaluates swallowing function if dysphagia is present 3
• Pain management specialist: Addresses neuropathic pain using gabapentinoids or duloxetine, as pain significantly impacts rehabilitation participation 2

Psychological and Social Assessment

• Screen for anxiety, depression, and psychological distress, which are frequent complications in chronic neurological conditions 3, 2
• Assess caregiver burden and availability of social support, as this impacts participation, safety, and outcomes 3
• Evaluate need for pain rehabilitation program if chronic pain syndrome with central sensitization has developed, as comprehensive pain rehabilitation can restore function in wheelchair-bound patients 3

Documentation Requirements

Medical Justification

• Document specific diagnosis (CIDP with motor predominance, sensory involvement, etc.) and medical justification for why patient cannot ambulate safely 1
• Specify functional limitations in clinical terms: "bilateral lower extremity weakness preventing safe ambulation" 1
• Include statement that less costly alternatives are insufficient: "cane and walker inadequate due to bilateral lower extremity weakness and balance impairment" 1
• Document pressure ulcer risk factors and need for specialized seating if applicable 1

Common Pitfalls to Avoid

• Do not delay assessment waiting for "optimal" disease control, as early intervention with appropriate equipment prevents secondary complications 3
• Do not prescribe generic wheelchair orders without specific evaluation, as improper fitting leads to skin breakdown, functional limitations, and safety issues 1
• Do not assume static disease course: CIDP fluctuates, requiring serial reassessment rather than one-time evaluation 3, 2
• Do not overlook cognitive and psychological factors that impact safety and rehabilitation participation 3
• Do not forget to assess home environment and community access needs, as wheelchair prescription must match the environments where it will be used 1