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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?

.


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.


 

Worldwide STOP Pressure Injury Day 

Thursday 19th November marks the Worldwide STOP Pressure Injury Day – a day to raise awareness of pressure injuries, and to promote education and collaboration to prevent their occurrence.   Many of us will be familiar with pressure injuries and their implications, both their impact on the person’s quality of life, and the cost to the health sector in treating them.  Worldwide STOP Pressure Injury Day offers us the chance to learn more about pressure injures and how we can assist in their prevention. 

One important source of information on pressure injuries is the ‘Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline’ released last year, which gives an evidenced based overview into the prevention and treatment of pressure injuries.  This guideline is available online for purchase or is accompanied by a quick-reference guide that is free to download.  For therapists, one aspect of pressure care we are frequently involved in is the recommendation of support surfaces – both for lying and sitting, hence it is worth us consulting the guideline and ensuring we are following best practice. 

One challenging aspect of support surfaces in the ongoing need for education on the correct use of any support surface.  For me, November has been a busy month for education about ROHO products, with the most common enquiry being ‘how do I know a ROHO cushion / mattress is inflated correctly’ closely followed by ‘how do I clean the ROHO cushion / mattress and its cover’.  Many of these enquiries have come from nursing staff who are new to working with ROHO, however many caregivers in the community are likely to have the same questions.  Part of our role when working with people who are dependent on a specialised support surfaces to assist in managing their pressure relief, is ensuring the person, and their wider team, understand how these support surfaces work and how to care for them.  We need to ensure they know how to check their support surface is working correctly, how to identify when it is not, and who they need to contact if they need help with repairs or maintenance.  In some instances, this can be a challenge due to high turnover of staff in some areas, meaning trainings may need to be frequently repeated, or written information provided that is easy for new staff members to follow. 

For those who frequently prescribe support surfaces, either mattresses or cushions, this week is a good opportunity to evaluate what tools you use, or resources you have, to assist in preventing pressure injuries.  What tools do you use to help identify who is at risk of developing a pressure injury?  Or what resources do you have to complement use of support surfaces?  Alternatively, this week could be a good opportunity to link in with your community nursing or wound care team - an excuse to meet if your paths don’t often cross despite often working with the same group of people.  This collaboration can be time well spent, as collaboration across teams or different departments often result in a more co-ordinated approach to service delivery, which ultimately benefits the person requiring the service.

So for this weeks Worldwide STOP Pressure Injury day, make sure you take some time to learn and some time to reflect.  Take some time to attend an event at your local hospital, or join an online webinar, or browse the Clinical Practice Guidelines or Quick Reference Guide.  Take some time to reflect on your practice and your contribution to preventing pressure injuries – because if each of us takes pressure injuries seriously we can reduce their incidence and prevent the reduction in quality of life that typically accompany them.

Resources

Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline or Quick Practice Guide link  https://pppia.org/guideline/

New Zealand Wound Care Society – Clinical and Public resources https://www.nzwcs.org.nz/resources/stop-pi-day

Wounds Australia – https://www.woundsaustralia.com.au/


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.

What Matters When Scripting a Manual Wheelchair?

Scripting ultra-lightweight manual chairs can be a challenge – what frame material do you choose? What frame design? And then there are all the measurements that you need to get…

When first learning to script manual wheelchairs, it can be hard to know what to focus on, however a recently published article by Lin and Sprigle can help give us some direction.


Lin and Sprigle’s study researched the operator and wheelchair factors on wheelchair propulsion effort, taking a group of 36 people and exploring which factors influenced their propulsion effort over a modified figure eight course.

Lin and Sprigle were keen to explore which factors really matter to everyday wheelchair users. The modified figure eight course was compromised of both tile and carpet surfaces, and thought to be more reflective of the stopping, starting and turning that wheelchair users do in their daily lives. The study group was made up of 23 existing manual wheelchair users who completed the study in their own chairs, and 13 able bodied people who were randomly assigned a pre-configured chair.

Both operator and wheelchair factors were explored. Operator factors included aerobic capacity, muscle strength, maximum propulsion strength and their shoulder position relative to the axle. Wheelchair factors included the mass of the chair, the weight distribution over the chair – given as a percentage weight over the rear wheel, and system friction. 

These factors were assessed over two separate sessions and included five minutes of propelling around the modified figure eight course. The results from these were then statistically analysed, and which factors that influenced propulsion effort identified.   

The results of this study showed that shoulder position of the user relative to the axle, and weight distribution of the chair had the largest influence on propulsion effort, particularly on the tiled surface. So, in other words, where the axle position was placed and where this position was relative to the user’s shoulders mattered.  And in this case, it mattered more than the overall weight of the wheelchair and the fitness of the user.

This result obviously applies to these particular testing conditions. Under different conditions, factors such as the user’s strength and fitness may have more influence.  Of note, the influence of weight distribution and axle position was less pronounced when the person was propelling on carpet, where the carpet itself was a significant factor in the person’s propelling efficiency. The chairs used in the study had a variety of castors and rear wheels with different amounts of friction produced which also produced some impact when propelling on carpet but was not as significant.

The weight distribution on a chair is related to the axle position, with a more forward axle position resulting in more weight over the rear wheels, and vice versa – where the influence of weight distribution on turning resistance is most noticeable when too much weight is towards the front of the chair.

The axle position relative to the shoulder is crucial for maximising the ergonomics of the person self-propelling, with both the axle position relative to the back posts and the height relative to the user being important. Establishing where to set the axle position for new users is often challenging. A more forward axle position results in a chair that is more ‘tippy’ which can be difficult for a new user to manage, while a more rearward axle position can result in a chair that feels ‘heavy’ to push and turn.

This is where adjustable chairs are useful and the axle position can be changed as a user becomes more confident in using their chair, allowing the chair to be configured for optimal efficiency over time.

The seating used on the wheelchair can also contribute to the relative axle position. A change of cushion can change the user’s height relative to the wheel, while a change of back support, or changing between a solid back support and an upholstery back (not to mention an upholstery back that becomes saggy with time) can change how far forward the axle sits.

Another factor that impacts on weight distribution on the chair is the body shape of the user itself – a person who has had both legs amputated above the knees will have no weight towards the front of the chair, while a person with oedematous legs may have more than usual. A bilateral above knee amputee can be challenging to set up as the chair needs to be stable, yet the rear wheel placed in a position to ensure efficient self-propelling. For this group, learning good wheelchair skills is important, while others may need anti-tips to ensure stability of the chair when using on uneven surfaces.

So, what is the one thing we need to get right when scripting a manual chair? The position of the axle – this can make a world of difference to the end user and how easy their chair is to manage. Not sure how to get this right? Consider starting with an adjustable chair and ask your local supplier or dealer with help to set it up. Then trial the chair in the places the person needs to use the chair to ensure that the set-up is just right.

Still wondering about the weight of the wheelchair? We’ll come back to this in a later blog!

Reference

Jui-Te Lin & Stephen Sprigle (2020) The influence of operator and wheelchair factors on wheelchair propulsion effort, Disability and Rehabilitation: Assistive Technology, 15:3


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.

The WhOM and Funding Reports  

Our last three webinars for 2020 are looking at funding and how to write successful funding reports.  Writing reports is a skill that some of us struggle more with than others, where understanding what information is vital to the funding report can be a challenge. In today’s blog we are taking a look at the WhOM and how it can assist with writing funding reports. 

Writing funding reports for wheelchairs can seem simple on the surface – a person is unable to walk, or does not have functional mobility, hence requires a wheelchair.  However the world of wheelchairs is not so simple, with wheelchairs being available in all sorts of sizes, configurations and with different features, and hence we need to be able to communicate to the funders why a particular chair at a particular cost is essential to meet a person’s needs.

In a previous role I worked as a Paediatric Physiotherapist, and worked closely with the local Orthotist, a very experienced person who was often very direct with his thoughts, and often in our joint appointments he would ask me outright – Rachel, what are we wanting to achieve here?  Which brings me back to the WhOM.

For those who are new to the WhOM – the WhOM is an outcome measures that focuses on participation – often the ICF domain that is most meaningful to end users.  The WhOM can be a means of establishing ‘what are we trying to achieve’ with a wheelchair, where mobility is expanded from moving from point A to point B, to ‘I want to be able to go into town without my parents’ or ‘I want to be able to cook my own meals’.  For our younger wheelchair users and their families, there is a modified version – the WhOM-YP.

The goals identified through the WhOM will be as diverse as the range of people we work with, and some of these goals will relate to funding guidelines, while others won’t – but each goal deserves to be acknowledged.  

The WhOM asks a person to score each goal on how important it is to them, and how satisfied they are with how they complete each goal.  Asking a person to rate how important a goal is to them can help differentiate between a goal that has been identified by another person (eg a caregiver or support worker) and what is meaningful to them, as well as prioritise intervention if different goals contradict each other – for example indoor and outdoor goals that are not able to be achieved in one mobility solution.  Asking a person to rate how satisfied they are with how they perform each goal will hopefully give you the opportunity to demonstrate that your intervention was effective – as their satisfaction score will hopefully improve post intervention. 

How well the WhOM influences the outcome can depend on what we do next.  The WhOM has helped us identify what we want to achieve, the next step is to work through is how we will achieve it.  Once we have established our goals we then need to work through each goal and analyse what is required to achieve it.  For our young person who is wanting to go to town on his own, it may be that we are looking at power assist for their manual chair, or time spent on improving wheelchair skills to manage on/off busses or crossing the road safely and independently. For our person who is wanting to cook meals independently we may be looking at ActiveReach or power standing, or adaptive equipment and strategies to compensate for reduced hand function. In other words, while the WhOM is an outcome measure that is designed for wheelchair users, the intervention that results from completing it may or may not be related to the wheelchair. 

This analysis often provides information to support a funding request – for example our person who is wanting to cook, as part of analysing this goal we have looked whether the person can access their kitchen in their wheelchair, confirmed that they have the hand function to complete the required tasks safely (with or without assistive equipment), they have the range of movement in their legs for ActiveReach, and alternative options have been considered, such as whether a caregiver is required to assist.  Failing to complete this analysis typically results  in funding reports that are lacking in information – and remember, the person who is reviewing the funding report has not met the person who requires the wheelchair – hence if the report does not contain the required information the funding body will not be able to support funding for what can be a high cost solution.   

Ultimately everyone involved in the wheelchair prescription and funding process is wanting to facilitate good outcomes for end users, our role as therapists is to be able to identify what these good outcomes might look like and communicate how a piece of equipment is going to achieve them in our funding reports.

The WhOM manual and assessment form is freely available online, for more information please see https://millerresearch.osot.ubc.ca/tools/mobility-outcome-tools-2/the-wheelchair-outcome-measure-whom/

For more information on our upcoming webinars



 

Rachel Maher
Clinical Education Specialist 

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

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service, working with children aged 0 to 16 years.  

Rachel later 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.

Mobility is a Human Right. Why we can’t ignore this topic anymore 

 


Did you ever attend a course, read an article, or hear a topic and think to yourself, “Yes, this is important. I need to remember this.”? But within a couple weeks this new topic or idea has left your mind. It happens to all of us. We get motivated by hearing someone’s passion, but how do we then take that motivation and implement it? 

Today in this blog what we are going to discuss mobility. It is something that I feel incredibly passionate about, but it is also something that we can no longer just forget. We, whether that is a clinician, family member, member of the industry, or the end-user, we have to find a way to remember. The research is there. We can no longer pretend that mobility does not impact well-being, health, independence, and function. We have the research, we have the equipment, now we have to act. Mobility is no longer just something that we hope to provide someone. 

Mobility is Human Right 

Now, to really help us to remember this, we need to first define what mobility is. I have given this definition in a previous blog, but I believe now that I was slightly wrong. Today, I am talking about independent mobility. My old definition of mobility was getting from point A to point B in the most efficient, safe, and timely manner. This definition does still hold true, but how we think about what point A and point B are can really make the difference. At first, I thought point A to point B was this distance say from the bathroom to the kitchen. This distance to be travelled. That is one form of mobility. There is also another way to think about mobility that I had missed.

 Let’s consider that point A is a moment or position in space and point B is a different one. What does this mean? What is the definition trying to say? We don’t have to define mobility as just getting from location to another location, but instead someone’s mobility could also mean their ability to move their body in space. Someone that is unable to move at all and utilises a power tilt independently to relax. Is this a form of mobility? I say YES! I believe we have missed out on some great opportunities to provide individuals with a form of independent mobility by missing what should be the definition of mobility. 

Now that we have this definition lets go back to our statement: Mobility is a Human Right. 

It can be easy for us as human beings to understand that someone that can walk should be allowed to walk. It can also be pretty easy to explain that when someone has the ability to push a manual wheelchair and we provide them a wheelchair, that we have given them independent mobility. But, what about the “harder” situations that we might come across as a clinician? What about someone that is “old” and lives in an aged care centre, should they really have a powered wheelchair or other appropriate device to move around? I often hear “Why does an old person need to be able to move?” 

Have we tried to give this “old person” a mobility device? Or is this an assumption based on another experience or perhaps our thoughts? Just because someone is older by year of age does not mean that they will be inappropriate for all mobility devices. Maybe the traditional idea of independent mobility is not an option due to cognition or safety, but what about having the ability to shift their own weight, move their legs or backrest position, or change their height?

Just because someone requires supervision or assistance to move their wheelchair does not mean that we can’t give them some form of independent mobility. You have to trial options. It might require some out of the box ideas, or perhaps you even have to spend time explaining why to a funder. 

Mobility is Human Right. It does not have an age limit where it all of a sudden doesn’t matter anymore. Put yourself in their position. Are you okay with losing your independent mobility once you hit a certain age? 65? 68? 72? At what age are you okay with no longer having the ability to move independently if there is a way to help you move? This goes for the other end of the spectrum as well… 

 


Age does not define your right for mobility.

We have to then also consider this for our youngest individuals. At what age should mobility begin? Let’s remember what the definition of mobility is: the ability to move in space. When a typical developing child begins to move, they learn and explore their environment. We don’t have to wonder what the impact of exploration is on development as it has been researched and reported. We don’t even have to wonder at what age we should start thinking about mobility devices as we can see the research describing this as well.

So, what is it that is holding us back in this age category? Is it parents? Or, is it us? Funding? It is easy for us to sit here and think of all the reasons why there are children that are 2, 3, even 4 years old that have never been given a chance for independent mobility. What impact does this have on the child? It is our responsibility based on our education and understanding of mobility and development to keep working towards access for everyone regardless of their age.

So, lets go back now to the beginning of this blog when I discussed the definition of mobility. We know now that we cannot just take away or limit someone’s mobility based on their age, but there is still a large group of individuals that are not young or old that have been forgotten. This is the group that might not be able to independently drive or propel their wheelchair. But do they have the capacity to move independently?

Can they activate a switch or button on the wheelchair and change their position? Can they maybe have their wheelchair programmed to drive at only a low speed? Just because an individual cannot independently drive a powered wheelchair at 10km/hr or propel a manual wheelchair up a hill, does not mean that we should give up on the idea of mobility for this individual.

Instead of focusing on what they can’t do, let’s focus on what they have the potential to do. I have seen some of the most incredible, out-of-the-box ideas across Asia and the Pacific to get an individual just a small amount of independent mobility.


I know this can be overwhelming and where we often start to let this motivation go and not turn into action. We are here to help. Whether it is a mentor, another clinician, or someone in the industry. Reach out for help.

If you don’t know where to start you can also contact your local Permobil representative to start discussing how to best give mobility to your client. You can also reach out to your Permobil Clinical Education team for support at 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. 

Rachel joined Permobil in January 2018 relocating to Sydney, Australia in June 2018 as the Clinical Education Specialist for Australia and New Zealand. In February 2020 Rachel moved into the role of Director of Clinical Education for Asia-Pacific.