June 16, 2003

The Honorable Donald Rumsfeld
Secretary, U.S. Department of Defense
c/o Ann N. Fazzini
Medical Benefits and Reimbursement Systems
TRICARE Management Activity
16401 East Centretech Parkway
Aurora, CO 80011-9066

Re:   ITEM Coalition Public Comments to TRICARE Changes Included in the National Defense Authorization Act for Fiscal Year 2002 (NDAA-02)

Dear Secretary Rumsfeld:

These public comments are submitted on behalf of a new national, consumer-led coalition known as the “ITEM” Coalition, which is an acronym for Independence Through Enhancement of Medicare and Medicaid. The Coalition is just forming and will be formally launched tomorrow, June 17, 2003. The opportunity to comment on a proposed regulation with such great relevance to the Coalition’s mission does not come along very often, and so we offer the following public comments for your consideration.

The ITEM Coalition comprises nonprofit consumer and provider organizations interested in advancing public awareness of and building support for public policy changes that will improve access to assistive devices, technologies and related services for people of all ages with disabilities and chronic conditions. Our coalition is focused on raising awareness about the full complement of assistive devices, technologies, and related services, including what is commonly defined as durable medical equipment, orthotics (orthopedic braces), prosthetics (artificial limbs), supplies, and a whole host of sensory and communication aids and other devices. This includes everything from the “lowest tech” grab bars for seniors with orthopedic impairments to the “highest tech” screen readers for people with vision impairments. It also includes the myriad devices that improve the function, independence, health status, and quality of life of people with disabilities and chronic conditions.

CONTENTS:
Background
Durable Medical Equipment
Rehabilitative Therapy
Augmentative Communication Devices/Speech Generating Device
Hearing Aids
Prosthetics and Orthotics
Conclusion
References

Background

Technology has the potential to unleash unprecedented levels of independent living and community participation among people with physical, cognitive, sensory and communication disabilities. Assistive devices and technologies, including both those items currently available and the more advanced technologies to come, can vastly improve functional levels of people with disabilities and enhance their quality of life. For both children and adults with disabilities, assistive technology can lead to greater participation, independence, productivity, and integration in the home, in the classroom, in the workplace and in the community.

The need for access to assistive devices, technologies and related services has been clearly demonstrated. Over fifteen million Americans with disabilities reported using assistive devices or technologies in recent surveys. (1) Data from 1994-95 indicated that 6.8 million Americans used some kind of assistive device for mobility, including approximately 1.7 million who used wheelchairs or scooters. (2) The number of wheelchair users today has grown to approximately 2.1 million. (3) Millions of Americans report living in homes and using cars or vans that have been modified to meet their special needs. (4) More than 2.5 million Americans report that they lack the assistive technology that they need, with about 70% citing cost as the primary reason. (5)

Less than 20% of the estimated 28 million Americans who could benefit from hearing devices currently have them. (6) In fact, 50% of assistive technology users and 75% of those with home modifications paid for this assistive technology themselves or with the help of family members, with no help from third party payers. (7) The barriers to access to assistive devices, technologies and related services have been documented to result in physical consequences, such as a general deterioration in health and a risk of secondary injuries, as well as strained relationships with family, friends, and colleagues, financial strain, decreased independence, and limitations in social participation. (8)

Access to assistive technologies and related services, however, is severely restricted for a number of reasons, not the least of which is restrictive coverage policies by “third party” payers such as Medicare, Medicaid, and other publicly financed programs or private health plans. Questions regarding the adequacy of coverage of this benefit category under the TRICARE program were raised in Senate hearings in the year 2000 and prior to that time. Congress acted on these concerns in the National Defense Authorization Act for Fiscal Year 2002 by significantly improving and expanding TRICARE benefits in this benefit category.

The result, we are happy to state, is a benefit package that, on paper, is arguably the most appropriate, most accommodating benefit package of any federal health program with respect to meeting the assistive device and related service needs of people with disabilities and chronic conditions of all ages. In fact, TRICARE’s coverage policies under this benefit package represent, in many respects, a model that the ITEM Coalition would like to see considered and adopted by other third party payers.

In practice, however, the ITEM Coalition is hopeful that TRICARE program officials will exercise their discretion in a manner that makes the promise of access to these benefits real. Because TRICARE is an appropriated program rather than an “entitlement” such as Medicare or Medicaid, the coverage decisions that ensue over the coming years will significantly depend on the level of appropriated resources available to the program. The intent of Congress in passing this new statute could not have been more clear. Congress intended that this new law would stimulate TRICARE to provide greater access to appropriate assistive devices, technologies and related services.

But the proposed rule states on a number of occasions that although the new statutory language does not specifically comport with the current regulations, and that TRICARE will adopt the new statutory language in the regulations, TRICARE’s “policies in place at this time provide coverage within these criteria.” Our concerns are underscored by the statement in the “Regulatory Procedures” section of the rule that this new regulation is “not economically significant….” 68 Fed. Reg. 18,577. If this language means that the TRICARE program does not anticipate spending any more resources on this benefit category than the program did before this new law was adopted, then the ITEM Coalition strongly objects to this interpretation of the statutory language. If this indeed is the case, we strongly urge that TRICARE explicitly recognize in the final rule that the new language represents an expansion of the benefit in question and rethink its requests for appropriations to meet the need created by this new language. Without this, the ITEM Coalition believes that the TRICARE program will be in violation of the intent of this new law.

Durable Medical Equipment (“DME”)

The statute requires coverage of any durable medical equipment that can improve, restore, or maintain the function of a malformed, diseased, or injured body part, or can otherwise minimize or prevent the deterioration of the patient’s function or condition. It also provides authority for coverage of any durable medical equipment that can maximize the patient’s function consistent with the patient’s physiological or medical needs.

The statutory and proposed regulatory language represents a tremendous step forward in a federal health program’s recognition of the importance of this benefit category and we commend Congress and TRICARE for setting this new standard of coverage. The new language specifically references functional status as the benchmark for coverage. In many health programs and plans, the standard for coverage consists of a restrictive interpretation of “medical necessity,” a term that oftentimes works against coverage of DME that improves the function, rather than the medical condition per se, of the beneficiary. Understanding that TRICARE-covered benefits must also be considered medically necessary, the ITEM Coalition strongly supports this reliance on functional status as an operative factor in the coverage determination process of DME under the TRICARE program.

In fact, the statutory language makes clear that the intent of the statute is to cover durable medical equipment across the continuum of functional status of the beneficiary. In virtually any health program that provides coverage of DME, such DME is provided to the beneficiary if improvement or restoration in medical or functional status can be demonstrated. But coverage is more often denied for DME when the provision of a particular device would maintain, more than improve, the person’s health or functioning. Even more common are denials of coverage when the provision of DME would minimize or prevent deterioration of the patient’s condition.

There are several factors that contribute to the inadequacy of DME coverage by health programs and plans. Under Medicare, for instance:

* The ability to increase one’s level of “independence” through the use of an item of equipment or device is given little or no weight in the coverage determination process;

* Dual purpose items, such as those that provide some type of benefit to the public but which also provide a unique and important health benefit to an individual with a disability, are not covered;

* The term “treatment” in Medicare’s medical need definition (42 U.S.C. § 1395y(a)(I)) operates against coverage of DME that is preventive in nature;

* Mobility devices will only be covered if they are medically necessary in the person’s home, regardless of the need to be mobile in the community setting; and

* Particular brands or types of self-selected or physician-recommended mobility devices are often not covered, but less expensive models are.

The new language of the statute and proposed regulations impact each of these factors in a way that should lead to a significant reduction in barriers to accessing DME and other assistive devices, technologies and related services. For instance, under the new statute, we would anticipate, assuming that other conditions of coverage are met, that TRICARE would cover certain sensory or communication aids such as screen readers, Closed Circuit TVs, or optical scanners for people with vision impairments whose deterioration in function could be reduced or prevented by the provision of these devices. Similarly, we would expect that TRICARE would potentially cover certain home modifications such as grab bars and raised toilet seats that facilitate better functioning with self care, safety, and may prevent conditions such as hip fractures and other injuries from falls.

The Medicaid program addresses this issue, in part, by making no express reference to “durable medical equipment,” in contrast to the Medicare Act. For Medicaid, the operative term is “equipment.” For example, the Medicaid home health services benefit includes, as a mandatory component, “medical supplies, equipment, and appliances suitable for use in the home.” 42 C.F.R. §§ 440.70(a); 440.70(b)(3). The use of the term “equipment” rather than the term DME permits such devices to not necessarily be “primarily medical” and may permit a device to have “dual uses” while still being covered by Medicaid. The TRICARE program should attempt to import these concepts into the coverage process of this benefit category.

The TRICARE program continues to require covered DME to be “primarily and customarily designed and intended to serve a medical purpose rather than primarily for transportation, comfort or convenience.” 32 C.F.R. § 199.2. The regulations also continue to prohibit coverage for “luxury” or “deluxe” items. These requirements appear out of step with the new statute’s standard of maximizing function and preventing deterioration of function. What these coverage policies expose is a lack of recognition of the relative needs of people with varying levels of impairment brought on by the particular circumstances of the individual. What may be a “convenience item” for one person may be the key to full functioning, independent living, improved health, and ability to work for someone else.

Technology has blurred the line between what can legitimately be called a convenience or luxury and what improves the functionality or quality of life of the person, thereby improving his or her health status. The Veterans Administration has made significant progress in this area, permitting coverage of up to three mobility devices for each mobility-impaired veteran in order to satisfy various activity demands. Recognition of the value of community participation and full function should not be considered a luxury or a convenience by the TRICARE program. We urge that in the final rule, the TRICARE program revisit the appropriateness of these outdated coverage policies in light of the new reliance on functionality reflected in the statutory and proposed regulatory language.

Restrictions on Access to Power Mobility: In the final rule, TRICARE should specifically address the issue of accessing power mobility before a long term manual wheelchair user is no longer able to propel him or herself due to secondary injury as a result of such wheelchair use. Many clinical studies have shown that prolonged manual wheelchair use is a major factor in the high incidence of secondary injuries to the upper limbs among wheelchair users, resulting in shoulder, elbow, and/or wrist pain. (9) Unlike most injuries, injuries to the upper limbs among manual wheelchair users are both relatively predictable and avoidable.

These injuries are predictable because incidence of upper limb pain has been directly correlated with the time of use of the wheelchair. (10) Additionally, certain patient populations, such as tetraplegics and quadriplegics, individuals with degenerative neurological conditions, and individuals with poliomyelitis, are at an increased risk of experiencing upper limb pain due to manual wheelchair use. (11) Accordingly, the research supports prescribing power wheelchairs to individuals with a high risk of upper limb pain, degenerative arthritis, torn rotator cuffs, and similar injuries due to prolonged manual wheelchair use.

Based on the extensive clinical data involving secondary injury from manual wheelchair use and this new statutory language that permits coverage of DME that prevents deterioration in function, TRICARE should make clear in the final rule when a manual wheelchair user may access power mobility. Power mobility devices should be available to the portion of the manual wheelchair population that faces imminent risk of significant secondary injury due to prolonged manual wheelchair use. This policy would very likely decrease the incidence and prevalence of secondary injury, which oftentimes manifests itself in costly medical/surgical corrective interventions. A sister agency of TRICARE, the VA, permits access to power mobility at age 55, for instance. An age threshold is one way to address this problem, but a clinical assessment, based on the individual condition of each wheelchair user, may be more appropriate. In addition to preventing secondary injury, of course, powered mobility devices are often essential to allow individuals to fully participate in the community and live independently (e.g., when traveling to doctor’s appointments and school and community gatherings).

Restrictions on Access to Vision-Related Technologies: In addition to mobility devices, there are a number of vision-related devices, technologies, and related services that should be covered by TRICARE and other health programs and plans as DME. Approximately 6.5 million people age 55 and older cope with severe vision loss, defined through the National Center for Health Statistics-Health Interview Surveys as inability to read ordinary newsprint even with the aid of corrective lenses.

Age-related vision loss is caused by eye conditions such as macular degeneration, glaucoma, diabetic retinopathy, and, in some cases, complicated cataracts. Each one of these eye conditions can have a significant impact on visual function. The most common types of equipment used to improve, maintain, and in some cases, restore, visual function are:

* hand-held or stand magnifiers often equipped with high intensity lights for performing close up tasks such as reading medication instructions;

* pocket size telescopes and lens attachments for distance vision to avoid accidents and prevent injuries;

* closed circuit television (CCTV) which magnifies and projects printed materials on a television screen in order to read them more easily;

* screen reader systems comprising synthetic speech and screen readers which tell synthesizers how to portray the information on the computer screen.

Each of these devices and/or technologies offer significant medical/functional improvement to the user and should be covered for TRICARE enrollees under the newly expanded definition of DME. An alternative would be to cover these devices as “prosthetic devices” under TRICARE as they “replace all or part of . . . the function of a permanently inoperative or malfunctioning internal body organ,” i.e., the eyes. 68 Fed. Reg. 18,577. Either way, these devices should be explicitly recognized in the final rule as being covered items under the TRICARE Program.

In addition to these devices, services related to vision care, such as vision rehabilitation services, should also be covered, presumably under the rehabilitation therapy benefit. Training in the use of assistive technology must be an integral part of the provision of technology itself. Individuals who are blind or severely visually impaired require a functional evaluation of the impact of the appropriate assistive technology. Beyond the functional evaluation, training services usually include, but are not limited to, selecting the proper aid, coordinating necessary therapy, and training and technical assistance for the individual in the proper use and maintenance of the device.

Customizing and Accessorizing DME: The new statute and proposed regulation clarify that the TRICARE program also makes available coverage to customize or accessorize DME if it is essential for achieving therapeutic benefit for the patient, making the equipment serviceable, or otherwise assuring the proper functioning of the equipment.

The ITEM Coalition strongly supports this language due to the importance of customizing and accessorizing DME to meet the specific needs of each beneficiary. The wide variety of physical disabilities, the severities of these disabilities, and the complications posed by an individual’s health status create an extensive diversity of disabling conditions that can only be adequately addressed if coverage of customization and appropriate accessories to DME is clearly established. A “one size fits all” approach with many forms of DME can lead to serious consequences for beneficiaries.

For instance, custom seating and positioning devices for people who are long term wheelchair users is vital to their health and functioning. If seating and positioning is not adequately customized to the needs of the user, the result can be the formation of decubitus ulcers and other skin breakdowns that could result in surgical intervention and extensive rehabilitation. Customized seating and positioning devices can also improve pulmonary function as well as prevent scoliosis.

Unfortunately, the language of the preamble to the proposed rule once again states that the program’s “policies in place at this time provide coverage within these criteria.” As already stated, the clear intent of the statute was to expand access to this benefit category, not simply restate a series of regulations. The ITEM Coalition, therefore, urges TRICARE to make this clear in the final rule and to request an appropriate level of appropriations to truly improve access to this benefit category.

Rehabilitative Therapy

The ITEM Coalition is focused on advancing coverage of assistive devices, technologies and related services. Such services are often covered by health programs and plans as “rehabilitative therapies.” The new TRICARE statute covers “rehabilitative therapy to improve, restore, or maintain function, or to minimize or prevent deterioration of function, of a patient when prescribed by a physician.” Pub. L. No. 107-107, § 704. This is similar to the language used under TRICARE’s new DME benefit, and it highlights the importance of providing rehabilitative therapies that prevent deterioration of function, in addition to improving or restoring functional abilities. In this manner, the ability to function without the necessity of using assistive devices and technologies may be prolonged. In addition, the ability to function with the use of assistive devices may be heightened.

The preamble to the proposed regulation states that the TRICARE program intends to interpret the statute to be limited to physical therapy, occupational therapy, and speech therapy, despite the fact that the statute clearly states that coverage would apply to any “rehabilitative therapy” that improves, restores or prevents deterioration of function. 10 U.S.C. § 1077a. The ITEM Coalition, once again, is concerned that this interpretation violates the intent of the statute, which was to expand access to rehabilitative therapy services. Because TRICARE already covers physical, occupational and speech therapies, the proposed regulation arguably subverts the intent of the statute.

There are a number of additional therapies that should be available for coverage under the TRICARE program based on the statutory language, assuming such therapies are prescribed by a physician. For instance, respiratory therapy should be explicitly covered in the context of providing oxygen equipment to TRICARE enrollees. In the hearing impairment context, audiologic diagnostic and treatment services should be covered. As already stated, vision rehabilitation therapy should be covered by the program when needed by a TRICARE enrollee. Recreational therapy services should be covered as well, assuming it is prescribed by a physician as part of a treatment plan to improve, restore or prevent deterioration of function. Music therapy and other services can also be effective for specific patients and should be covered under the same circumstances.

All appropriate therapies should be covered in the context of training a TRICARE enrollee in the use of an assistive device or technology with which they are unfamiliar. In addition, there may be other rehabilitative therapies that should be considered for coverage on an individual basis under the broad mandate of the statute. Unfortunately, the proposed regulation seems to have interpreted away much of the promise of this provision in the statute. The ITEM Coalition urges TRICARE to not arbitrarily limit coverage to the therapies it currently covers but to adhere to the letter and spirit of the law by expanding coverage to “any rehabilitative therapy” (10 U.S.C. § 1077a) that improves, restores, or prevents deterioration in functional status, assuming such therapy is prescribed by a physician, is considered medically necessary, and meets the other requirements of the program.

Augmentative Communication Devices (ACD)/Speech Generating Device (SGD)

The TRICARE statute provides coverage for augmentative communication devices as “voice prostheses.” Termed “speech generating devices” or “SGDs” by the Medicare program, TRICARE proposes to adopt the same nomenclature. However, it should be noted that Medicare covers SGDs as durable medical equipment while the TRICARE program explicitly covers them as prosthetic devices because they replace the function of an internal body organ, i.e., the larynx. This is an important concept for TRICARE to adopt in that many sensory and communication aids, including devices used by people with impaired vision or hearing, replace the function of an internal body organ as well (e.g., in the vision context, the eyes; in the hearing context, the ears). The ITEM Coalition is hopeful that the TRICARE program will expand upon this concept and cover a number of these assistive devices through administrative determinations.

We applaud the TRICARE program for adopting many of the provisions that Medicare has adopted on the issue of coverage of SGDs rather than recreating a whole new set of standards. SGDs are newly covered benefits under TRICARE and we are appreciative of the fact that TRICARE developed the proposed rule on this issue in consultation with ITEM Coalition member organizations with expertise in the SGD field.

Hearing Aids

The TRICARE statute explicitly covers hearing aids for dependents of a member of the uniformed services on active duty and only if the dependent has a “profound” hearing loss. Medically necessary and appropriate services and supplies, such as a hearing examination required in connection with the hearing aid benefit are also covered.

The ITEM Coalition strongly supports this provision in that, like SGDs, the new statute will bring coverage of hearing aids to TRICARE enrollees for the first time. The statute does limit the hearing aid benefit to those with “profound” hearing loss, a term that appears in the statute and that TRICARE defines in the proposed rule. While the ITEM Coalition would prefer that this limitation not exist, we understand that TRICARE must not contravene the statute.

We support the coverage of medically necessary and appropriate services and supplies that accompany hearing aid care, in particular, hearing examinations. We urge that audiologic diagnostic and treatment services be considered by TRICARE as covered benefits under either this provision or under the rehabilitative therapy benefit. For a successful outcome, a hearing device must be accompanied by audiologic rehabilitation.

Prosthetics and Orthotics

Under current law, the TRICARE program covers “[p]rosthetic devices, as determined by the Secretary of Defense to be necessary because of significant conditions resulting from trauma, congenital anomalies, or disease.” 10 U.S.C. § 1077(a). The new statute enhances the TRICARE program’s prosthetic benefit by clarifying that the Secretary has authority to provide prosthetic care in the following circumstances:

1) where any accessory or item of supply used in conjunction with the prosthetic device would achieve therapeutic benefit and proper functioning;

2) for services that are necessary to train the recipient of the device in its use;

3) repairing the device for normal wear and tear or damage; and

4) replacement of the device if it is lost or irreparably damaged or the cost of repair would exceed 60% of its replacement cost. 10 U.S.C. § 1077(e)(1). In addition, TRICARE covers replacements of prosthetic devices “when required due to growth or a change in the patient’s condition.” TRICARE Policy Manual, Chapter 7, §4.4(D) (March 2002).

The ITEM Coalition applauds the TRICARE program’s expansion of its prosthetic benefit which will now be at least as generous as Medicare’s coverage criteria. However, we are concerned that these same coverage policies apparently are not being applied to the program’s orthotic benefit. This seems to be occurring despite the fact that TRICARE clearly covers orthotic care (orthopedic braces and related services) (32 C.F.R. § 199.4(d)(3)(viii)) and the benefits enumerated in the statute, such as supplies and accessories, training, repairs and replacements, are just as relevant in the orthotic context.

Indeed, after speaking with Congressional staff, there is evidence that Congress intended to apply the statutory provisions to both prosthetic and orthotic care. Due to the similarities in the related fields of prosthetics and orthotics, and the similar needs of TRICARE enrollees who require orthotic and prosthetic care, the ITEM Coalition encourages TRICARE to explicitly recognize in the final rule that orthotic care is covered under the program and that the statutory provisions that apply to prosthetic care also apply to orthotic care.

Conclusion

Thank you for the opportunity to submit public comments on this proposed rule. The ITEM Coalition is very encouraged by the expansiveness of the TRICARE benefit under the new statute and regulations and views the TRICARE benefit package in this benefit category as a real model that should be adopted by other public health programs and plans. We look forward to working with the TRICARE program as this proposed rule is finalized, funded, and implemented.

Submitted by the undersigned members of the ITEM Coalition:

Adapted Physical Activity Council
Advancing Independence: Modernizing Medicare and Medicaid
Alexander Graham Bell Association for the Deaf and Hard of Hearing
American Academy of Audiology
American Academy of Neurology
American Association for Homecare
American Association of People with Disabilities
American Association on Health and Disability
American Congress of Community Supports and Employment Services
American Congress of Rehabilitation Medicine
American Foundation for the Blind
American Medical Rehabilitation Providers Association
American Music Therapy Association
American Occupational Therapy Association
American Physical Therapy Association
American Therapeutic Recreation Association
Amputee Coalition of America
Assistive Technology Industry Association
Association for Education and Rehabilitation of the Blind and Visually Impaired
Association of Academic Physiatrists
Association of Tech Act Projects
Blinded Veterans Association
Brain Injury Association of America
Christopher Reeve Paralysis Foundation
Consortium of Developmental Disabilities Councils
Council of Citizens with Low Vision International
Disability Service Providers of America
Easter Seals
Eastern Paralyzed Veterans Association
Families USA
Helen Keller National Center
Inclusion Research Institute
Long Island Center for Independent Living
Medicare Rights Center
National Association for the Advancement of Orthotics and Prosthetics
National Association of Developmental Disabilities Council
National Association of Protection and Advocacy Systems
National Association of Rehabilitation Research and Training Centers
National Campaign for Hearing Health
National Council on Independent Living
National Spinal Cord Injury Association
Paralyzed Veterans of America
Research Institute for Independent Living
Self Help for Hard of Hearing People
Spina Bifida Association of America
The Arc of the United States
United Cerebral Palsy Associations

References

(1) Carlson, D., Ehrlich, N., Berland, B.J., and Bailey, N., Assistive Technology Survey Results: Continued Benefits and Needs Reported by Americans with Disabilities, National Institute on Disability and Rehabilitation Research (NIDRR), 2001.

(2) National Health Interview Survey on Disability, Phase I file, National Center for Health Statistics, 1994-1995.

(3) United States Census Bureau, Americans with Disabilities: Household Economic Studies, 2001 (using 1997 data).

(4) Carlson, et al., 2001.

(5) LaPlante, M.P., Hendershot, G.E., and Moss, A.J., Assistive Technology Devices and Home Accessibility, National Center for Health Statistics, 1992.

(6) Kochkin, S., and Rogin, C., Quantifying the Obvious: The Impact of Hearing Instruments on Quality of Life, The Hearing Review 7(1): 6-35 (2000).

(7) LaPlante, M.P., et al., 1992.

(8) Neri, M.T., and Kroll, T., Understanding the Consequences of Access Barriers to Health Care: Experiences of Adults with Disabilities, Disability and Rehabilitation 25(2): 85-96 (2003).

(9) Pentland, W. E., and Twomey, L. T., Upper Limb Function in Persons with Long Term Paraplegia and Implications for Independence: Part I, Paraplegia 32: 211-18 (1994) (finding the following pain prevalence among paraplegics: shoulder 39%, elbow 31%, and wrist/hand 40%); Cooper, Rory A., et al., Research on Physical Activity and Health Among People with Disabilities: a Consensus Statement, J. Rehabil. Res. Dev. 36(2): 142-54 (1999) (“Manual wheelchair users are particularly susceptible to rotator cuff tears, lateral epicondylitis, and cubital tunnel or carpal tunnel neuropathies due to micro-injury caused by the repetitive motions required to propel themselves.”); Dalyan M., et al., Upper Extremity Pain After Spinal Cord Injury, Spinal Cord 37(3): 191-5 (1999) (based on study of patients with spinal cord injury, 71% reported shoulder pain, 53% wrist pain, 43% hand pain, and 35% elbow pain).

(10) Nichols, P.J.R., et al., Wheelchair User’s Shoulder?, Scand. J. Rehabil. Med. 11: 29-32 (1979) (“One-third had at least one attack of cervico-brachial pain within one year. The frequency [and] duration of the attack tending to increase as time passes. . . . After ten years, 54% have cervico-brachial pain.”)

(11) Curtis, Kathleen, et al., Shoulder Pain in Wheelchair Users with Tetraplegia and Paraplegia, Arch. Phys. Med. Rehabil. 80: 453-57 (1999) (“In the current cross-sectional study, both the prevalence and intensity of shoulder pain during the performance of functional activities was significantly higher in subjects with tetraplegia than in subjects with paraplegia.”); Pentland, W. E. and Twomey, L. T., supra note 20 (“Wheelchair users whose extremities are already compromised by weakness and muscle imbalance (e.g. quadriplegia, poliomyelitis, degenerative neurological conditions) may be especially at risk [for upper limb pain].”).