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How to set up a ROHO® QUADTRO SELECT® Cushion

 

The ROHO® QUADTRO SELECT® Cushion is one of our most popular choice of cushion. For those of you who are less familiar with the functionality, how to correctly set-up or adjust this cushion, or perhaps, why you would choose this style of cushion from our ROHO® range, then this week’s blog post is for you.

What is a QUADTRO SELECT® Cushion? 

It is an adjustable, air-filled, cellular-design wheelchair support surface that uses our DRY FLOATATION ® Technology.  The cushion is intended to conform to an individual’s seated shape to provide skin/soft tissue protection, positioning and an environment to facilitate wound healing.  

Although there is no weight limit, the cushion must be properly sized to suit the individual. 

The QUADTRO SELECT® cushion features four independent compartments of air cells, each controlled by our exclusive ISOFLO® Memory Control located at the front of all Select Series cushions, this includes our CONTOUR SELECT® Cushion

What is the ISOFLO® Memory Control? 

The ISOFLO® Memory Control allows air to flow through the cushion in two ways:

ISOFLO Memory Control shown in the OPEN position.

Air can flow freely throughout the entire cushion, similar to a ROHO® Single Compartment Cushion.

ISOFLO Memory Control shown in the CLOSED position.

Air becomes locked into four separate quadrants, offering front-to-back and side-to-side positioning capabilities. 

The cushion is available in our 3 profiles. High Profile which has a 4 inch cell height, Mid Profile which is a 3 inch cell height and our Low Profile which is 2 inch cell height. The set up is the same with all 3 profiles.

 

Why does the ISOFLO® Memory Control look different?

There has been a minimal design change to the ISOFLO ® Memory Control. The function remains the same however the lock and unlock icons have been replaced by a green circle, indicating a single compartment cushion, or 4 red circles indicating a 4 compartment cushion.

Before Re-Design

After Re-Design

 

Who would benefit from a ROHO® QUADTRO SELECT® Cushion?

The Quadtro or Contour Select is a great choice if an individual needs a cushion that provides both pressure redistribution and positioning needs. Consider the individual who is sitting in a posterior pelvic tilt and the impact this posture has on the persons ability to eat, drink, talk and breathe! The goal is to ensure the individual is sitting in the most comfortable and midline posture as tolerated.

The set up guide below will explain how to set up the select cushion range, as a single or four compartment cushion and how to either accommodate or correct a posterior pelvic tilt or pelvic obliquity using the ISOFLO® Memory Control.

How to set up a ROHO® QUADTRO SELECT® Cushion

We have created a simple QUADTRO SELECT® Set Up Guide which you can access here.

For those of you who are more of a visual learner, here is a great animated video showing the correct set up of a QUADTRO SELECT® Cushion. 

 

 

 

 
Dee Smith 
LTC / Aged Care Clinical Specialist  

Dee is a Registered Nurse with almost 25 years’ experience in a variety of specialities.   

She graduated from Sydney University with a Bachelor of Nursing in 1997 and in 2001 gained a Post Graduate Certificate in Infection Control. She has Certificate IV in Training and Assessment.  

Over the past few years Dee has been working within the Aged Care Industry as a Clinical Nurse Consultant in Infection Prevention & Control, to assist Residential AgeCare Facilities in meeting the requirements for the Aged Care Quality StandardsDee developed and delivered education and training of evidenced-based practice in Infection Prevention and Control, Wound Care and Pressure Injury Management.  

Dee joined Permobil in 2020 as the Seating and Positioning BDM and in 2021, joined the Asia Pacific Clinical Education team as Long Term Care/Aged Care Clinical Specialist. Dee is passionate about mentoring, educating and empowering health care professionals to provide safe and quality care.  

Can attendance at an Expo count towards ongoing professional development?  


The past 14 months have brought many challenges to the way we learn, interact and access seating and wheelchairs. Online platforms and virtual education have been embraced and provided opportunities for all therapists including those who often miss out due to remote locations and high caseloads. However, there is nothing like being able to interact and try equipment to fully understand the capacity of the technology!  

As we move towards the “new norm” we are excited to be involved in the return of the Assistive Technology Association Expos and Clinical Education program on both sides of the Tasman. Both these events follow a similar format with a large exhibition featuring the latest and greatest AT solutions all under one roof alongside clinical workshops and presentations.

It is important for therapists attending to remember if you are claiming the hours towards ongoing competency requirements that just attending a workshop or presentation isn’t necessarily meeting the requirements. Clinicians need to relate the content back to both their scope of practice and personal learning goals. One of the benefits of having an expo alongside a program is the ability to consolidate and apply some of the clinical concepts to the equipment on display. Whilst there are some fundamental similarities between products there are also differences that we need to consider when identifying potential solutions that will meet the individual functional needs of an end user. It is a great opportunity to compare different potential solutions and stay up to date with the latest features and technological advancements. Along with our Product Specialists our Clinical Education Specialists will be on stand at both the Australian and New Zealand events and welcome you to stop by with any questions if you are attending.

These events are valuable not just to prescribing clinicians, end users and those that support individuals with an impairment can also find value from both the clinical program and talking to suppliers, manufacturers, and service providers. comparing.

Melbourne will be the first to kick off. The Australian ATSA have events in 3 states this year, Victoria, Western Australia, and ACT. The clinical education program is available for Melbourne and Perth events and Rachael Fabiniak and myself are both presenting and will be on the expo stand to assist with any queries throughout the events. You can register online for these free events. See ATSA website for the complete programme.

Melbourne - Tuesday 17 May 2021

Melbourne - Wednesday 18 May 2021

Perth Wednesday 26 May 2021

 

New Zealand is not missing out with a similar opportunity in July! This will be held Tuesday 6 – Wednesday 7 July 2021 at the Sir Woolf Fisher Arena, Vodafone Events Centre, Manukau, Auckland New Zealand. Rachael Maher will be on stand throughout the event and Rachael Fabiniak and myself will be streaming live from Australia. Their full program is available here. 

Tuesday 6 July 2021

Wednesday 7 July 2021

If you are unable to attend either of these free events but are interested in any of these workshops or other clinical education opportunities, please reach out to us at Education.APAC@Permobil.com or your local Permobil Educator.

This year also sees the return of the Oceania Seating Symposium. This is a hybrid event to enable presentations from seating experts from around the globe to still present their latest research, findings and all things seating related and a great opportunity for those clinicians that want to further develop their knowledge around seating and mobility. This Symposium is hosted by Seating to Go under the umbrella of the International Seating Symposium and Pittsburgh university further information can be found here http://oceaniaseatingsymposium.com/welcome/ (Link)

With all these events and opportunities,Can attendance at an Expo count towards ongoing professional development? Yes, if it matches your development goals, just remember to keep it purposeful if you are planning on claiming these hours. If you are at any of these events stop by our stand and say hello, we would love to see you!


 

Tracee-Lee Maginnity
Clinical Education Specialist 

Tracee-Lee Maginnity joined Permobil Australia in July 2019, as a Clinical Education Specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.  

Tracee-Lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

 Are we proactive with power assist?


Power assist is a hot topic on my calendar for May this year, and has seen me reviewing educational material relating to power assist in recent weeks.  In my presentation I have one slide that I am wrestling with, and this relates to our current approach to power assist – and whether we are proactive or reactive?                                                                                                                                                                                             

A big part of me wants to say that we are well on the way to being proactive in our approach, but another part of me questions whether we truly are?  Power assist is no longer new technology, it has been available for some time now and there are numerous options on the market. There is research to support that power assist helps a wheelchair user travel further with less effort, and not to mention consistent statistics about the rates of shoulder pain and/or injuries in people who rely on manual wheelchair for their mobility. As therapists we know this information, but do we apply it to our daily clinical practice?

When we assess a person for a potential wheeled mobility solution, we are good at establishing how a person functions, what environments they need to access and what goals they have relating to wheeled mobility, and for those who have clear goals relating to power assist, or an obvious need for power assist, we are good at recommending it.

But what about those whose need for power assist is less obvious? For some users who are having challenges using a manual wheelchair we often consider a power wheelchair in the first instance – for example children, or older people, or those who live in residential care, perhaps with the perception that power assist is complex, or not cost effective, or not practical for indoor environments. Despite these perceptions, the challenges of power wheelchairs remain the same – power wheelchairs are heavy – making them more challenging to transport, their footprints can be larger – making them more challenging to use in smaller spaces, and finding a chair that meets functional needs (such as a lower seat to floor height) can make them a high-cost item.

There are many instances where a power wheelchair is the more appropriate solution, but with advances in power assist technology it may be that power assist can be an option for more manual wheelchair users. More power assist options now have programming options – the option to programme the device to move nice and slowly for the older person punting in a residential care facility, or to have strength differences programmed into wheels for the person who has asymmetrical arm strength (or who may struggle with camber on the footpaths). The practicalities of power assist have also improved – many options are now easy to attach or detach, for the child who only needs assistance to get down the back of the school field to join his friends to play. The range and reliability on some options is approaching that of a power wheelchair, allowing a person to use power assist to access the community from their own home, reducing their reliance on public transport or taxis.


                                                                                                                                                                     

One article I discovered while researching power assist was by Giesbrecht et al (2009) who compared a power wheelchair with a pushrim activated power assisted wheelchair with eight wheelchair users who used both manual and power wheelchairs. The study was small, and for those who used their power wheelchairs for the majority of their day, the overall trend was they preferred their power wheelchairs, but there were features of the power assist devices they liked – particularly aspects such as weight and manoeuvrability. The part of the study I found surprising was that many users were able to complete the majority of their desired activities in both their power wheelchair and the power assisted manual wheelchair, this makes me wonder what this same study would look like today with the range of options we now have available.

One debate that does come up around power assist is whether it is cost effective. Is it a cost-effective means of a person being able to achieve their goal? Is it a cost-effective solution in general? How do I justify a power assist solution to the funder? Unfortunately, not all power assist options will meet government funding criteria, some may need to consider whether they have the means to self-fund a solution, while others may need to explore other funding options. Establishing whether a solution is cost effective is multifactorial, where we need to weigh up how a power assist option compares to other potential solutions. For example, provision of a power assist option may eliminate the need for a modified vehicle or housing modifications when compared to a power wheelchair, or it may allow a person to access the supermarket independently, meaning they do not need a paid carer to help them. A more challenging aspect to quantify is whether provision of the right device will mean that it is actually used – and not left sitting abandoned in a person’s garage, an unfortunate consequence when we don’t get the match between the person and solution right.

So how do we be more proactive in our use of power assist? Maybe we need to be considering power assist for all manual wheelchair users? Maybe we need to be considering power assist before we consider a power wheelchair, regardless of a person’s age or living situation? Perhaps we need to be truly listening to our person’s goals and aspirations and working through what is required to achieve these, not just focusing on what a particular funding body will support?  Food for thought….


                                                                                                                                                                                        

Want to learn more about power assist?  Please reach out to our education or sales team to find out more – (insert details)

References

Giesbrecht, E.M., Ripat, J.D., Quanbury, A.O. & Cooper J.E. (2000) Participation in community-based activities of daily living: Comparison of a pushrim-activiated, power-assisted wheelchair and a power wheelchair.  Disability and Rehabilitation: Assistive Technology. 4(3): 198-207


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users. 


How to select wheelchair seating components for the prevention and treatment of pressure injury?

We would like to introduce a new resource, designed to assist in the multidisciplinary approach to selecting wheelchair seating components for pressure injury prevention and treatment.

We created this in collaboration with our Permobil Americas Education Team and the Pan Pacific Pressure Injury Alliance (PPPIA) to produce a Cobranded Guide.

Over the past few months we worked closely with Dr Emily Haesler the Methodologist & Editor-in-Chief of the 2019 International Guidelines and Professor Keryln Carville the PPPIA Chair, to produce this pocket guide and would like to thank both for their advice and expertise.

This new resource is called the Wheelchair Seating Pocket Guide and is available for download here.

It is based on the recommendations and best practice statements included in the 2019 International Guideline. It is intended as a brief overview and is best read in conjunction with the full 2019 International Guideline and the free abridged Quick Reference Guide which are available here.   

In this week’s blog, we would like to highlight some of the evidence-based recommendations from the International Guidelines in relation to the seated posture, along with providing some tips on selecting the appropriate components for seating. 


What type of individual should be using a high specification seating support surface?

The number one factor in common among all wheelchair users is impaired mobility. As stated in the introduction of 2019 International Guideline, “a number of contributing or compounding factors are associated with pressure injuries; the primary of which is impaired mobility.” 

Seating support surfaces specifically designed for tissue offloading should be used with individuals with certain risk factors, instead of “entry-level” surfaces. As outlined in the recommendations and good practice statements in the 2019 International Guideline, the following factors increase the risk of developing a pressure injury (PI).  

If any of these apply, refer the individual for a seating and wheelchair mobility evaluation: 

  • Limited mobility and limited activity
  • Previous/current pressure injury
  • Alterations to skin condition over pressure points
  • Pain at pressure points
  • Diabetes mellitus
  • Perfusion and circulation deficits 8
  • Oxygenation deficits
  • Impaired nutrition
  • Moist skin
  • Increased body temperature
  • Older age
  • Impaired sensory perception
  • Obesity 

What are the considerations with the seat support (cushion) when pressure injury prevention and treatment are the goals? 

Every surface in daily use needs to be taken into consideration. For individuals who use a wheelchair, a quality cushion with tissue offloading properties, is only as good as the system it is placed in. 

The ideal seating system consists of: 

  • The wheelchair base, correctly configured to match the individual’s measurements and range of motion limitations
  • The back support, which positions the trunk to optimise pelvic positioning, further aiding in the prevention and treatment of a pressure injury
  • The seat support (cushion) which will immerse and envelop or offload for optimal pressure redistribution and positioning
  • Any needed accessories to add stability, redistribute pressure, and allow for function 

Consider other seating support surfaces that the individual would utilise throughout the day such as, a shower commode, car seat, bed mattress and other seating surfaces. 

For this reason, when the need for tissue offloading has been identified, a referral to a specialised seating therapist is warranted. 


The Optimal Seating System Equation  

Experts in seating and positioning are successful in positioning their clients because they understand the critical interplay between the cushion, the back support, the wheelchair configuration and any needed accessories to create an optimal seating system. 

Positioning an individual optimally, will take much more than just a cushion. The trunk can never be addressed without considering the pelvis and the pelvis cannot be addressed without considering the trunk. With every seating referral, remember this simple seating equation as a reminder to think of all critical components of the SEATING SYSTEM.

Knowing when to refer your client for an assessment by another health professional is an important aspect of your role. It may be in regards to a seating assessment by a specialist, or in regards to another concern you have with your client which is outside your scope of practice, such as a newly identified skin lesion or significant weight loss. 


The Multidisciplinary Approach to Pressure Injury Prevention & Treatment

The recognition, treatment, and prevention of a pressure injury is a multidisciplinary, team effort. It is important to understand your role as a health professional in this process. Roles and responsibilities vary across clinical settings and geographic locations; however, an individual-centred approach to care is a gold standard. The primary focus for everyone involved is care delivery centred around the individual and meeting their wants, needs and goals.

Here is a diagram showing the main members of the multidisciplinary team for pressure injury prevention & treatment, however this is not an exhaustive list.

  

For more information, download your free copy of the Wheelchair Seating Pocket Guide  

If you are interested in more information in regard to Pressure Injury Treatment & Prevention, make sure you download the brand new Pressure Injury Guideline Mobile App launched in March 2021, called the InterPIP.  This International Pressure Injury Prevention and Treatment Quick Reference Guideline Mobile App is a joint creation between the Worlds 3 leading Pressure Injury Advisory Groups – NPIAP, EPUAP and PPPIA

 


 

 

Dee Smith
LTC / Aged Care Clinical Specialist
 

Dee is a Registered Nurse with almost 25 years’ experience in a variety of specialities.  

She graduated from Sydney University with a Bachelor of Nursing in 1997 and in 2001 gained a Post Graduate Certificate in Infection Control. She has Certificate IV in Training and Assessment. 

Over the past few years Dee has been working within the Aged Care Industry as a Clinical Nurse Consultant in Infection Prevention & Control, to assist Residential AgeCare Facilities in meeting the requirements for the Aged Care Quality StandardsDee developed and delivered education and training of evidenced-based practice in Infection Prevention and Control, Wound Care and Pressure Injury Management. 

Dee joined Permobil in 2020 as the Seating and Positioning BDM and in 2021, joined the Asia Pacific Clinical Education team as Long Term Care/Aged Care Clinical Specialist. Dee is passionate about mentoring, educating and empowering health care professionals to provide safe and quality care. 


 


When prescribing a wheelchair and seating system there is usually discussion on what are blanket branded as accessories When we look to the definition of an “accessory” we find:

NOUN - a thing which can be added to something else in order to make it more useful, versatile, or attractive. "a range of bathroom accessories"

synonyms:     attachment · extra · addition · add-on · retrofit · adjunct · appendage · appurtenance · (additional) component · fitment · supplement.

By definition we could consider headrests and laterals as accessories, but how well will the seating system work with asymmetrical postural needs without these components? Whilst a cup holder is an addition that is useful and potentially versatile it’s not part of the seating outcome so much as an accessory that aids functional independence. There is an array of solutions that could assist in the task of carrying a drink from different accessories through to task adaptation. However, when we consider seating requirements it can create confusion when we use this wording accessory - especially when we are justifying equipment applications for a reader that may have little or no clinical experience. It is important to consider the language we use when articulating needs and using clear clinical justification for all the essential components of the solution.

Postural supports should not be seen as merely useful add ons but as a fundamental part of the overall solution. 


The seating system

With the increased images of end users in new equipment flooding some social media platforms we often see some unique and amazing modifications and configurations of AT solutions, but it also highlights some frequent and common configurations that have a cookie cutter feel to them. Of course you cannot know the background, history, assessment findings or goals for these images, they are just moments in time caught on camera but it does highlight some fundamental oversights commonly seen in the prescription process. Let us take the backrest for example. Most manufacturers offer a selection of back heights within the selected style, this can be further configured with how and where it is mounted onto the wheelchair. The back height is particularly crucial when identifying functional use such as for an active self-propeller or in a tilt in space chair.  I have seen numerous images of children in active user style manual wheelchairs with back rests at shoulder height or higher. This configuration can have a negative impact on the child’s functional ability and the development of an effective push stroke. We want to provide support when required but also enable freedom for function. Some of these set ups are also utilising shoulder harnesses and when the back height is not inline with the shoulder you cannot achieve the appropriate line of pull. In NSW Australia I have seen many backrests set up and integrated into the function of the headrest. It was a common solution with some population groups through various custom seating clinics. However from my experience these were only as effective as the contouring and materials used, for individuals with postural positioning requirements the ability to provide angulation and appropriate support it is tricky to achieve when extending a back support to integrate occipital support.  And this brings us back to Accessories vs Postural supports…is a head support an accessory or a crucial part of the solution? 


Headrests

When prescribing any seating component, we are essentially matching needs identified from the assessment to product parameters that provide points of control or forces that will support those needs. As such, identification of a headrest should be part of the initial postural solution rather than viewed as an extra add on at the end. What do we need to consider when identifying a potential head support?

A properly configured and positioned head support is an essential component of wheelchair. The position of the head can affect common activities and daily functions such as:

  •          Socialization and communication
  •          Safe Swallowing
  •          Respiration
  •          Attention to Task
  •          Mobility

The first question to address is around the intended use. Is there a postural requirement to provide support, is it for resting when in tilted position or is it too meet safety recommendations when using the chair as an occupant seat in transport? Each of these reasons will guide the potential solution. 


Head Support for postural support

The head position will affect posture and balance just as posture and balance affect head positioning. Poor seating positioning, unbalanced musculature, decreased innervation and neural disruptions can all contribute to head position. Understanding where the head needs to be supported is crucial for best outcomes. 

When considering a head support, a posterior head support is usually the simplest and least restrictive, as such this is likely to be an initial consideration. The pad is designed to be positioned in the suboccipital area with the goal to prevent excessive extension, rotation, or lateral flexion.

Other considerations include:

  •          Address pelvis head and trunk alignment before trying to fit for a head support.
  •          Remember that head position changes constantly with the slightest body movement.
  •          Aim to position the pad in the suboccipital area posteriorly and avoid resting on the ear if positioned laterally.
  •          Consider a head support with lateral, anterior/posterior, height, and angle adjustability, that can support the head                     posteriorly and laterally.
  •          Choose head support hardware that has offset capabilities to accommodate a head position out of midline.

 


Head Support in tilt n Space  

 It is considered best practice to prescribe a headrest for mobility bases with tilt in space or recline features. It is important to consider the different impact that movement of the users centre of gravity will have on head positioning when utilising these chair features. Ensure it has been set to maximise support in positions required without impeding function in a neutral position.

The head support should not be seen as just an add on; clinical consideration, function and seating principals need to be applied to the clinical reasoning process. A head support should not be a prop for poor positioning or a last minute add on but an integrated consideration. 


 

Tracee-Lee Maginnity
Clinical Education Specialist

Tracee-Lee Maginnity joined Permobil Australia in July 2019, as a Clinical Education Specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating. 

Tracee-Lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.


Individual (noun)  

-       a person who thinks or behaves in their own original way

-       a single person or thing, especially when compared to the group or set to which they belong

(dictionary.cambridge.org)

Last week saw Permobil launch their latest brand video ‘Innovating for Individuals’ which includes a message that goes beyond marketing and extends into good clinical practice. 

‘We are all individuals with unique interests, needs and goals’..."Instead of searching for the things that we do the same, lets champion the things that set us apart’

Humans are interesting creatures, many of us love being a part of something greater than ourselves – we take great pride in the sports teams we follow or the ethnic or religious groups we associate with, however we also love being seen for who we are as individuals. None of us like being referred to by a label, nor are we happy when others make an assumption about us based on a group that we may belong to. 

As therapists we are typically loyal to our profession and will often playfully tease other professional groups, however each profession is made up of a diverse range of individuals. 

The same holds true of those with a disability – some may associate strongly with others with the same condition, but each is an individual with their own unique hopes and dreams. 

In recent years there has been a shift in how we refer to those who access health services, from ‘patient’ to ‘client’ to more recently the ‘person’, reflecting the person who exists outside their need to access health care. The person who has a family and friends, hopes and dreams, wishes and desires like each of us reading this blog. The person wants to be seen for who they are, not by the health challenge they have or the intervention they require.  

As therapists we know this to be true, however sometimes the nature of how organisations operate or the funding models we obtain equipment from can impact on how well we ‘see’ a person – we might be contracted to provide an intervention that may or may not be what the person actually needed or wanted, or we may be focused on ‘functional’ or ‘essential’ mobility instead of a person’s goal to play cards with their friends at the local bridge club.

Thinking of a person as an individual is incorporated into the ICF model, in particular identifying the personal factors about that person. ICF personal factors include gender, age, coping styles, social background, education, profession, past and current experience, overall behaviour pattern, character and other factors that influence how disability is experienced by the individual.

Taken from the ICF manual, ‘the functioning of an individual in a specific domain reflects an interaction between the health condition and the contextual: environmental and personal factors’, with a complex, dynamic and often unpredictable relationship between these entities. In other words, how the different aspects of the ICF interact with each other is complex, with a person’s environmental and personal factors helping give context to how the person is functioning. 

Like the other ICF domains, personal factors include factors that are modifiable and non-modifiable, with aspects such as age, race, and time since injury being non-modifiable. Other factors such as level of education, marital status and personality are deemed modifiable, reminding us that as humans a part of us will change over time. The review by Smith, Sakakibara and Miller (2016), which explored factors influencing participation in social and community activities for wheelchair users, the one personal factor identified related to the level of education. Higher levels of education were associated with increased access to employment opportunities, which is likely linked to greater levels of participation in the community in general. 

These personal factors can be what makes clinical practice meaningful – many of us enjoy meeting and getting to know new people and helping them achieve their goals in what can be some challenging times. The personal factors mean that providing a power wheelchair for a person with Cerebral Palsy becomes facilitating Andy being able play with his friends on the field at lunchtime. Or providing a manual wheelchair for a person with Multiple Sclerosis becomes helping Jane remain employed in a job she loves.

I still remember the lesson from physio school about how different people with the same problem can present differently – the example given was how 10 people with a sprained ankle may need 10 different strategies to manage their injury. The same holds true for wheelchair prescription – 10 different people with the same presentation of Motor Neuron Disease may require 10 slightly different solutions – and these differences can be the difference between a person achieving their goals and thriving, or potentially abandoning their equipment in favour of a different means of managing.  An example that comes to mind was the mother who requested a manual tilt in space chair in place of a power wheelchair – as they did not have the means to transport a power wheelchair, and being able to watch her children play sport was more important to her than independent mobility around her home. 


Innovate (verb)

-       to develop a new design, product, idea etc

-       to introduce changes and new ideas

(dictionary.cambridge.org)

Innovation is what has helped the industry move forward with new solutions, often prompted by wheelchair users wanting to achieve more. As science and technology move forward so do our solutions – we have power assist solutions that are lighter weight, more reliable and more durable.  We have manual wheelchairs that are lightweight yet strong, and we have power wheelchairs that are ‘smarter’ and going further. However, the journey towards better products is ongoing, with manufacturers continuing to show innovation either with developing new products or improving on their existing, not content that what we have now is the best that can be achieved.

Innovation can be also something we strive for in clinical practice, particularly when we have a person who requires more than what off the shelf items can offer. It might be that we are modifying an existing item, repurposing an item or having an item custom fabricated by a technician or manufacturer. Whether it’s the arm support that sits at just the right height in just the right place to maintain an independent transfer, the custom swing away tray that allows a person to carry items independently but also transfer independently out of their chair. Or the alternative drive controls that set up and programmed just so to keep a person driving. 

While the “Innovating for Individuals” brand video is ultimately a great marketing tool, it has also captured the sentiment of the industry, an industry many of us are part of as:

‘We believe everyone should have the right to live the life they want for themselves’. 


References

Smith, E.M, Sakakibara, B.M. & Miller, W.C. (2016) A review of factors influencing participation in social and community activities for wheelchair users. Disabil Rehabil Assist Technol.  11(5): 361-371 

How to use the ICF – A practical Manual for using the International Classification of Functioning, Disability and Health (ICF) downloaded from https://www.who.int/classifications/drafticfpracticalmanual.pdf 


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.


 


This is something that I recently thought about when teaching a course on power assist. This topic does not just relate to power assist but to all Assistive Technology (AT).

First, let’s define what I mean when I say proactive versus reactive. The dictionary defines proactive as “taking action by causing change and not only reacting to change when it happens”. While reactive is defined as “reacting to events or situations rather than acting first to change or prevent something”. What approach should we be taking when consider assistive technology? This is not always just a simple answer. We may be seeing an individual who this is not their first prescribed AT device and maybe we feel that we would have made a change sooner to the prescribed AT.

We also need to consider the funding and where the funding is coming from for the individual using the AT. Can there be a potential to be too proactive and cost additional money to the funding system/body? How do we weigh the options and know if something will be required or needed in the future?

The simple answer is that we have to use our best clinical judgement. This should not just be based on the individual’s diagnosis or the clinician’s past experience with similar cases, but it should be based on numerous factors that when looked at together can help to determine the necessity of an AT solution. One of my favourite ways to really look at all these factors is to use the ICF model as shown below. This can help to determine if there are any current changes that need to be made to the individual’s AT (reactive) or whether we need an immediate change to the AT to prevent any impacts to an area in the ICF model. Let’s look at an easy example to start.

 


Case 1

A cushion in a wheelchair. Now, I’m not talking about a specific cushion but just a cushion in general in a wheelchair for someone that is a full-time wheelchair user and perhaps has limited sensation. We know the importance of a cushion to help protect from a pressure injury (PI), but should we go ahead and get the cushion before anything is wrong or let them sit without a cushion and wait until they develop a pressure injury? I would hope everyone reading this would say “of course, the individual requires a cushion for their wheelchair”.

We understand the challenges of healing a pressure injury, the cost associated with the PI, and the impact it has on someone’s health and well-being. So, we can see the need for being proactive and not waiting for the event (PI), but instead working to prevent it. This can be an easy way to discuss how proactive AT solutions can often save overall lifetime costs and allow the individual to maintain their lifestyle, independence, health, and well-being.

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Case 2

What about those cases or AT solutions that are not as straight forward? Let’s look at another case example. A 42-year old female who has been using a manual wheelchair for more than 10 years, but suffers from shoulder pain with limited range of motion. Due to limited propulsion resulting in decreased independence, you are suggesting that she is prescribed a power wheelchair. It is also the first time you are working with this client.

You prescribe a power wheelchair with the power seat function tilt for this individual. You were not able to prescribe the power wheelchair sooner since this was your first time with the client, but have you been proactive in your approach? Have you considered all the options? What was one key that I had listed? Limited range of motion in the shoulders. If we moved the client to a power wheelchair because of shoulder dysfunction, did we think proactively about the power seat functions that she will need to access her environment? If the client has limited shoulder range of motion and pain, are we considering their goals and functional capacity in relation to the position they are seated in their wheelchair and the power seat functions they have access to? Does the client ever need to reach overhead in her environment?

If they need to reach overhead and we do not prescribe a power seat function that assists them, then what happens to the client? Maybe they continue to try to reach overhead with pain or perhaps they cannot due to the range of motion and their independence is limited. Despite just seeing the client for the first time, is it a proactive approach? Or, reactive? If we are reactive, have we really made change and reacted to address the whole situation if we only include power tilt?

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Case 3

One final example. A client that is a 28-year old male who is about to get his second manual wheelchair. He recently moved and now lives outside of the city but travels into the city daily. He takes public transport, but he still has to push quite a distance to and from work daily and for all his community activities that he enjoys. He would like to have a replacement of his manual wheelchair. You complete a full assessment and note that he has no pain and full range of motion throughout his body. The client also reports that he is able to achieve all of his activity and participation goals, but that it is getting harder now that he has moved. It often takes twice as long to get to where he wants to go and feels quite fatigued, so he has been going out less.

When you hear this case, what comes into your mind? Are you thinking about how the client could get around more efficiently if he had something like a power assist device? The client states that he does not have pain, but is that the only reason for someone to get a power assist device? After the shoulder pain begins, how much harder will it be to address the issue? We might be proactive here in trying to decrease the risk of shoulder pain, but what else are we doing? The client stated that he is already having a change in his activity and participation level, so is this truly proactive or are we just proactively trying to prevent shoulder dysfunction and being reactive to the changes in the client’s activity and participation level?

It can be a challenge to be truly 100 percent proactive, but are we looking at the whole person and environment and considering all the options? We have to determine the impact of being proactive versus reactive and how that balances with prescribing an AT device. I love using the ICF model to consider how the AT device might positively or negatively impact the individual. This can create my platform and reasoning for justification to funding as well. Remember to also utilise your clinical best practice guides and research to support your decisions, especially when making a proactive decision.


Have questions about funding? In NZ Reach out to Rahel.Maher@permobil.com or education.au@permobil.com


 

Rachel Fabiniak, PT, DPT
Director of Clinical Education – Permobil APAC

Rachel Fabiniak began her studies at The Georgia Institute of Technology, where she graduated with her Bachelor of Science in Biology in 2009. Rachel then went on to receive her Doctorate in Physical Therapy from Emory University in 2013.

After receiving her doctorate, Rachel went into clinical practice as a physiotherapist in the Spinal Cord Injury Day Program at Shepherd Center in Atlanta, GA. There she developed a passion for seating and mobility which ultimately lead to her career with Permobil.


 

When Do We Consider Renting AT Equipment?

Today we will discuss some situations where rental may be a beneficial option to consider. Over the years I have been contacted frequently about renting Assistive Technology (AT) for mobility and seating, from basic entry level through to complex solutions.


Interim Use

Interim use often refers to short term use whilst waiting for your regular equipment to be funded or repaired. In these situations, someone needs something and needs it now, How would you get about your day, complete all the activities and tasks that you need to do if your mobility was suddenly taken away? Could you sustain your daily activities of life? How would you be impacted not being able to go to school, to work, to the supermarket, out to see friends or attend appointments? Whilst there are various funding models, each of these works in slightly different ways and have different processes.

There are also different waiting times within each model and whilst most will offer funding or a means of repairing equipment how can someone continue with their day to day life without access to equipment to support their mobility?

Some disability service providers, hospitals or community groups may have loan pools where members or clients can access various AT for short term use. These vary and often include donated equipment so may have limitations in sizes and features. Whilst they may include equipment that is adjustable, they don’t always have someone available to reconfigure to a user’s specific needs.

This can be a great solution if you can match the users essential short term needs to equipment available however the more specific the users needs the more difficult this can be due to resources and availability of complex equipment. As seating therapists, we are usually striving to fit the equipment to the individual and their needs, rather than fit the individual to the equipment. Let’s consider scenarios where someone may want or need to rent for interim use.

 


Repairs and Maintenance

Whilst we don’t like to compare a mobility base to a motor vehicle in terms of functional use, when we look at the mobility base independently it also requires ongoing servicing and maintenance and can require mechanical repairs. Just like a car, maintenance may require waits for parts or completion of work to ensure it continues to be reliable and to meets client requirements. The service provider completing repairs and maintenance may have a mobility base that can be borrowed however if the user’s mobility base has certain features or specific configuration, a non-complex loaner may not meet their functional needs.

In this situation a user may want to consider renting a chair that is more specifically suited to their needs. Seat-to-floor height or seat elevate, for example, may be essential for the user to maintain independent transfers, the user then may require additional support not usually required. The impact of not having access to a mobility base that meets their needs is potentially not only affecting their mobility, but on them getting into or out of bed which could additional support and resources.

It is important to have a plan for what happens if the user doesn’t have access to their essential equipment as breakages and mechanical repairs are not always predictable! Do you have a plan for your clients if things go wrong?


Waiting for the Funded Solution

As discussed earlier there are different funding processes and the biggest difference between Australia and New Zealand’s government funding for disability is the order that the process takes when applying for equipment; In Australia an assessment is completed, equipment trialled and then an application is made for funding. Once funding is approved the equipment is ordered and an average of 6-8 weeks later, the equipment is delivered. In New Zealand the assessment takes place and the application to trial specific options is submitted, once approval is given a trial will be set up and there is an opportunity to keep the trial chair if it is successful.

As such the wait times and where the wait times occur do differ. An interim use chair may be required based on the users needs while they await assessment, funding or delivery of new equipment.

Renting equipment can also assist therapists and users identify how certain features or configurations can impact on function and assist in identification of potential solutions to trial. In Australia the trial time is limited to an appointment with the supplier which only provides a small snapshot of the user’s life and function. It may be appropriate to consider options for a longer trial period to fully identify what works and doesn’t work for a user.

We are aware of several users that have rented complex mobility bases before proceeding with funding as they wanted to ensure certain features where used or considered in multiple environments.


Short Term Use

Short term use is when the user doesn’t need their equipment long term, it may be part of rehab or assist someone in getting home from hospital post-surgery. This equipment is usually less complex and if required for hospital discharge is often loaned or rented from the hospital or arranged by the hospital staff. Short term rental is often considered when it is more cost effective than purchasing equipment that won’t be needed in the future.

Short term rental can also be an option when someone is travelling and not wanting or able to take their equipment with them. Travelling and resources may mean that someone takes a manual chair but wants a powered chair to explore and independently access the locations as they would normally at home in their power chair. 


Intermittent or Occasional Use 

Off road or all terrain chairs and beach chairs are often essential to access certain locations. How frequently will they be used? These chairs will not usually be practical for everyday use, so can be a large cost for occasional use that don’t meet some funders’ criteria. What will be the most cost-effective solution? If someone lives on a farm or rural location, they will potentially be using the equipment daily. But if it’s for an annual holiday to the beach or to the farm, renting may be an option to consider.

How can I rent mobility and seating solutions? 

  • Funding for rental may be available in some situations, this is best to addresses with your specific funding body
  • Talk to your therapist or service provider about potential options 

If you want to discuss any essential clinical features and options you feel are essential in an interim or short-term mobility or seating base, contact us at education.au@permobil.com. If you are looking at renting any Permobil products you can find more information on our Rental page.


Tracee-Lee Maginnity
Clinical Education Specialist

Tracee-Lee Maginnity joined Permobil Australia in July 2019, as a Clinical Education Specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating. 

Tracee-Lee is passionate about maximising functional outcomes with end users and the importance of education within the industry.

Alternative Funding Options 


It is important that as prescribers we understand the funding criteria and can articulate both the clinical justifications and how these can or cannot be met within the funding framework. Why do some applications fail to get approved and what are the options in these circumstances? Sometimes a person’s equipment needs may not fit within the funding requirements. In other cases it’s that a clear picture of the needs hasn’t been articulated. 

Either way, not getting funding approval for Assistive Technology (AT) doesn’t mean it’s not needed. In fact, if we have assessed and identified a specific need and identified a feature as a necessary part of a solution, we need to ensure that the end user understands the why’s and how to’s to inform future decision making. Today’s blog discusses some of these options and challenges. 

Funding not approved for essential equipment needs 

If a funding application has been declined and you feel it fits within the funder’s criteria and has been clinically justified through assessment, most funding processes have ways to appeal and this should be considered. In these situations, we initially need to understand why. Is it a mis interpretation of the criteria or has the justification not been clearly articulated? Consider what reasoning and feedback was provided by the funding body. 

Not meeting funding criteria 

Both New Zealand and Australia have really good funding systems. In fact, when compared to other countries around the world we could say we have some of the best funding opportunities for AT internationally. But funds are not infinite and to ensure that essential needs for more people are met there are certain limitations within each system. This can be difficult for someone to understand who has needs and requirements viewed from the perspective of their lived experience. As such we do need to be able to have clear, open communication around what can be funded. Whilst we may still identify a need there may be an ethical requirement to seek alternative options.

When prescribing AT it is important that we understand the criteria of the funding body. If someone is not going to meet the criteria, then we need to have the discussion early on and support the user to make an informed decision about their options. There are often options in this scenario such as co-funding where certain features are not fundable. But if the provision of the AT or a feature is essential to the user you may need to seek alternative funding.

Self Funding

In communities where equipment is routinely funded it is sometimes hard to have conversations around self funding. We shouldn’t assume that someone doesn’t want or can’t financially contribute to their equipment. If a colour choice or accessory is not within the criteria but important to the user they may wish to self fund the up charges. It is important they are aware of the options and choices around this. As a mum I would have definitely considered paying for light up castors for my child’s wheelchair for the annual school disco, but as a therapist this would have been something I potentially wouldn’t have felt comfortable justifying.

Crowd Funding and Fundraising

Self funding also doesn’t necessarily mean someone has the financial means to pay themselves. A popular fundraising movement of crowd funding has seen communities come together to help raise funds through online and digital platforms which often reach beyond a person’s community. Others may opt with more conventional fundraising through local events, family and friends.

Charities

There are many charities that contribute to assisting people financially. These also often have criteria and some prioritise equipment needs not funded by government funding agencies. Knowing these organisations and requirements can help us to identify potential options. Most require a supporting letter or application from the therapist involved. Is the user involved in any local organisations that may have funding or sponsorship opportunities?

Local support groups and associations for specific disabilities or impairments may also be an avenue to consider as a resource of financial support and advice in relation to equipment needs.

As mentioned earlier we are fortunate with our funding systems across Australia and New Zealand. The take home message is that if something is assessed and will assist someone in living their best life we should consider all options and know the funding parameters and alternative options available.

If you are wanting to know more about funding in AU and NZ, we are currently running a webinar series on this topic. The feedback and response shows how important a part of the AT prescription process this is! Part 3 is live next Thursday, 10th December – don’t forget to register here. If you missed Part 1 and 2, don’t panic! These were recorded so you can keep an eye out on the replay schedule here. 


 

Tracee-Lee Maginnity
Clinical Education Specialist

Tracee-Lee Maginnity joined Permobil Australia in July 2019, as a Clinical Education Specialist. She graduated Auckland University of Technology with a BHSc (Occupational Therapy) in 2003 and has since worked in various roles related to seating and mobility including assessing, prescribing and educating.

Tracee-Lee is passionate about maximising functional outcomes with end users and the importance of education within the industry. 

Clinical Reasoning in Wheelchair and Seating Prescription 


This week we are taking a quick look at clinical reasoning and how it applies to prescription of wheelchair and seating items.  Clinical reasoning is a tricky concept to define, and while universal to all health professions, the exact process appears to vary a little between professions.  There is some research available into clinical reasoning, however most of it involves clinical reasoning for medical professionals or exploring how clinical reasoning is taught to students.

Looking at the research does help give us a definition for clinical reasoning, Gummesson, Sunden and Fex (2018) state clinical reasoning may be explained as being the professional thought process, or the decision-making process, that a clinician undertakes when working with a person.  Delany and Golding (2014) state that clinical reasoning involves gathering and analysing information as well as deciding on therapeutic actions specific to the patients circumstances and wishes, Young and Thomas et al (2020) state clinical reasoning reflects the thinking or reasoning that a health practitioner engages in to solve and manage a clinical problem.   Cited in Edwards and Jones et al (2004), clinical reasoning can be described as a process in which the therapist, interacting with the patient and others (such as family member or others providing care), helps patients structure meaning, goals, and health management strategies based on clinical data, patient choices and professional judgement and knowledge.

Clinical reasoning can differ between therapists of different levels of experience, for example students mainly use a more analytic way of reasoning, where they seek answers from their theoretical knowledge to explain their findings, while more experienced therapists tend to rely on patterns they recognise without full analytical thought process, however experienced therapists will engage in an analytical thought process when presented with something unfamiliar.  (Gummesson, Sunden and Fex 2018)

Edwards and Jones et al (2004) explored clinical reasoning processes in a group of experienced Physiotherapists with different specialities (musculoskeletal, neurology and community) and proposed that physiotherapists use a mixture of hypothetical-deductive reasoning along with narrative reasoning, to acquire an understanding of the person as well as the disease

Hypothetical-deductive reasoning can also be known as diagnostic reasoning, where a therapist attempts to diagnose the underlying concern, and throughout the treatment process will continually evaluate as to whether this reasoning continues to hold true, for example, assessing the impact of an intervention and checking whether the response is in keeping with the initial diagnosis.

Narrative reasoning on the other hand seeks to understand the unique lived experience of person through their stories or narratives, to allow the therapist to gain insight into the person’s experience of pain or disability and their subsequent beliefs, feelings, and health behaviours.   

The combination of these two models of clinical reasoning balance the need to optimally diagnose and manage person’s presentation but also understand and engage with the person’s experience of that disability and pain. 

In our Funding 101 webinar we explored the use of the ICF framework as a means of collecting the wide range of information required to assist in writing a funding report.  A funding report also requires us to demonstrate our clinical reasoning process, so in other words showing our thinking as to how the identified solution will meet the persons identified needs and goals.  This clinical reasoning process needs to incorporate information obtained during our assessment process and may incorporate both a hypothetical-deductive reasoning approach and a narrative approach.  Clinical reasoning to support provision of a wheelchair is often the easy part – a person may have a complete spinal cord injury and is no longer able to walk, hence they require a wheelchair for all functional mobility.  In addition to showing rationale for provision of a wheelchair, we also need to demonstrate clinical reasoning to justify additional features or the additional cost of a higher specification chair  – for example our person with a complete spinal cord injury requires a scripted chair to allow for optimal configuration to maintain shoulder health (as per the RESNA position paper), and they may also require a power assist device to allow them to continue to work in their large workplace or to be independently mobile in their community to allow them to attend activities with their children. 

This clinical reasoning process can help identify what parameters a solution requires, for example the person needs a power assist device that is easily transported in their standard car, or a solution that works well on the varied terrain in their community.  Identifying the parameters of a solution required then matching a particular product to those parameters can assist with documenting our clinical reasoning, as opposed to just stating that a person requires a particular product. 

Another component of clinical reasoning involves considering alternative solutions and balancing up the benefits and challenges of each solution identified.  For example, each power assist device comes with its benefits and challenges, not to mention an actual power wheelchair may be also be a potential option.   This can be where our narrative reasoning can help us – for example incorporating a person’s desire to remain self-propelling or whether or not they are willing to change their vehicle to accommodate a proposed solution.  This narrative reasoning can also expose some challenging issues, such as the person who refuses to consider trialling a power wheelchair despite their lack of functional mobility in a manual wheelchair, or the person who wants to trial of a piece of mobility equipment that is potentially beyond their ability to safely manage due to their progressive condition.

When it comes to how we explain our clinical reasoning in our reports, a study by Delany and Golding (2014) provides a little insight.  Delany and Golding looked at a group of educators working with students – these were educators from a variety of health professions, who explored their own clinical reasoning processes and looked at how to translate this into teaching of their students.  A point that emerged from this study was how the educators had to be more concrete and explicit about their knowledge and reasoning when describing their clinical thinking to a colleague from a different discipline, for example a Physiotherapist needed to explain their clinical reasoning clearly to an educator that had a Social Work background in order for the Social Worker to understand their clinical reasoning process.  This might be something we need to keep in mind when writing our reports – in that the person reading the report and approving the funding may not have the same professional background as the person writing the report.

Where the trial occurs in the report writing process varies across funding options, however the trial does give us a chance to add information to our clinical reasoning process – for example if we are exploring use of a power wheelchair as a means of reducing fatigue, a trial will allow us to establish whether this proves to be true.  In some cases a trial can be a source of new information – for example a persons cognitive abilities may  become clear when trialling a power wheelchair, or new goals may emerge when a person realises what opportunities a change of mobility solution may offer them.

Many of us will have the clinical reasoning abilities discussed here, however how well we are able to articulate them, or document them in a report, will vary.  A useful strategy for improving on your ability to articulate or document your clinical reasoning is to discuss your reasoning with a person who is not familiar with the person you are writing the report about, this can help identify any gaps in your reasoning or challenge any assumptions you have made.  This is likely to result in a report that is easier for the funders to follow and reduce the time taken to get approval for a solution, allowing the person to receive their equipment and fulfill their goals sooner.

For more information on writing successful funding reports, please join us for our next webinar.

Funding 102: How to write successful funding reports in 

Thursday 26 November 2020 starting at 12.00pm 

Register HERE

 


References

Gummesson, C., Sunden, A., & Fex A. (2018). Clincal reasoning as a conceptual framework for interprofessional learning: a literature review and a case study.  Physical Therapy Reviews 23 (1) 29-34

Delany, C., & Golding, C. (2014). Teaching clinical reasoning by making thinking visible: an action research project with allied health clinical educators.  BMC Medical Education 14 (20) https://doi.org/10.1186/1472-6920-14-20

Young, M.E., & Thomas, A. et al (2020). Mapping clinical reasoning literature across the health professions: a scoping review. BMC Medical Education20(107) https://doi.org/10.1186/s12909-020-02012-9

Edwards, I., & Jones, M. et al (2004). Clinical Reasoning Strategies in Physical Therapy. Physical Therapy 84 (4) 312-330 


Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.

Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.

Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.