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Early Milestones: Developing Proximal Stability

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Welcome to Part 4 in our series about developmental milestones in early childhood focusing on mobility. See Part 1, Part 2, and Part 3 in case you missed them earlier!

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A young infant begins by weight bearing through hands, knees and toes. This proximal stability is what allows him to hold his head against gravity. This is a critical part of development. At two months of age this action is what facilitates head control and is linked to oculomotor control which is the foundation of visual skills.

At this point the infant begins to develop visual fixations and is able to bring both eyes (controlled by six oculomotor muscles) together to stabilise his gaze. Infants who have not developed this trunk control lack the ability to gain full head and eye control. Without proximal control of the trunk and the development of eye gaze, a child’s development will be greatly altered.

 

 

The seat surface and opportunity for weight bearing in the Explorer Mini aims to mimic this posture to augment the non-mobile infant.

So while a young child may not yet have full head control, the use of the Explorer Mini provides a supportive seat and weight bearing surface to encourage further development of the trunk, visual and vestibular system while providing proprioceptive input which stimulates co-contraction at the weight bearing joints, to help promote improved head control. 

How sitting typically develops:

3-5 Months: Pre-sitting period, single postural muscles are activated. For an infant at this age they need postural support and opportunities for supportive sitting.

5-6 Months: A young child can sit with arm support.

7-10 Months: The leg, trunk and neck muscles are activated and cooperate in sitting and reaching activities.

9 Months to 3 Years: The young child has good modulation of pelvic muscles for a stable base of support.

3 Years and Beyond: The child needs less co-contraction and the use of neck muscles for postural control (6).

 

 

How does the Explorer Mini provide postures to mimic the stages a young child goes through for sitting?

For the non-ambulatory child, a stable base of support is realised in the Explorer Mini by many contact points and a wide base of support, as is provided in a variety of positions by the adjustable seat and tray surfaces. In contrast to a device that positions the child in a non-active sitting position, a child will typically assume a slumped posture with weight bearing behind the ischial tuberosities and no mechanoreceptors are activated. 

The saddle seat surface of the Explorer Mini places the weight bearing in front of the ITs to facilitate weight bearing through the upper extremities, while the pelvis is positioned in a forward/anterior tilt, with the hip position signaling the erector spinal muscles (or back muscles) to activate.

This device not only allows a young child to independently move, but it also promotes postures that may help them reach developmental milestones over time. Rather than limiting non-mobile young children to lay in a stroller or bed, we can use the Explorer Mini to help trigger muscle activation in postures that are safe and stable.

1.Hagert, E., Persson, J., Werner, M., & Ljung, B-O. (2009). Evidence of wrist proprioceptive reflexes elicited after stimulation of the scapholunate interosseous ligament. American Society for Surgery of the Hand, 34A. 642-651.

2.Henderson, A., & Pehoski, C., (2006). Hand Functions in the Child: Foundations for Remediation, 2nd edition. Mosby, Elsevier. St. Louis, Missouri.

3.Michelson, JD, & Hutchins, C., (1995), Mechanoreceptors in human ankle ligaments. The Journal of Bone and Joint Surgery. British vol. 77-B

4.Rosenblum, S., & Josman, N. (2003). The relationship between postural control and fine manual dexterity. Physical and Occupational Therapy in Pediatrics, 23,(4). 47-60.

5.Stavness, C., (2006). The effect of positioning for children with Cerebral Palsy on upper-extremity function: A review of the evidence. PT and OT in Pediatrics, 26,39-52

6.Westcott, S., & Burtner, P. (2004). Postural control in children: Implications for pediatric practice. PT and OT in Pediatrics, 24, 5-55.

7.Scheiman, M. (2011). Understanding and managing vision deficits: A guide for occupational therapists. Thorofare, NJ: SLACK Incorporated.

 

 

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS

Associate Professor in the School of Occupational Therapy at Belmont University

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS is an Associate Professor in the School of Occupational Therapy at Belmont University in Nashville, TN. She has over 40 yrs of OT experience and 20 in the area of Assistive Technology.

She is a member of the International Society of Wheelchair Providers, and the Clinicians Task Force. She is a reviewer for American Journal of OT and guest reviewer for many other journals. She has authored journal articles and textbook chapters in the area of OT and pediatric mobility and access.

 

At what age can a child use the Explorer Mini?

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Part 3 in our series about developmental milestones in early childhood focusing on mobility. 

 

The characteristics of the Explorer Mini take into consideration developmental milestones and the hierarchical nature of these achievements.

The 3-5-month-old child begins pre-sitting skills activating the postural support muscles. He draws on earlier achieved skills such as visual fixation, which occurs at 2 months of age, consistent with the onset of propping prone on forearms. The weight bearing that occurs in prone on forearm elicits co-contraction of the gleno-humeral (shoulder) joint muscles which provides the proprioceptive input for joint stability. This promotes upper trunk girdle activation by facilitating the thoracic extensor muscles to engage which in turn encourages head and neck extension. 

It is this co-integration of trunk extension with head extension and the visual vestibular interplay that promotes proximal stability

A young child who is able to hold his head upright, or recover head control if temporarily lost, and make postural corrections in a supported sitting position may benefit from use of the Explorer Mini to help promote further development of proximal stability. This allows the other sensory motor skills to gradually integrate. The device is designed for upper extremity weight bearing, like propping up on forearms, that would be a necessary foundation for upper body control. The Explorer Mini provides trunk, pelvis and upper body support to help an infant progress with sitting skills. The infant will be in a position to put weight through the forearms which will promote shoulder joint stability and encourage trunk extension and head control.

While the Explorer Mini is designed for 12-36 month old children, the pre-requisite motor skills are compensated for by the inherent support in the design of the sitting and trunk support surfaces (1,2,4,6). In fact, the device is designed to promote sitting by providing a wide base of support and many points of weight bearing including the feet, the pelvis and the forearms.

Proximal Support and Distal Mobility

Regarding the efficient control of the joystick, the infant with a supported seating posture begins commanding distal motor control once the support or sitting skills are initiated. In other words, one needs proximal support or control to command distal mobility. They are inextricably linked and codependent. You can see this in infants who have mastered independent sitting and are able to manipulate toys with their hands. 

Essentially, the postural activation transmits “action plans” to the motor cortex of the brain to control movement of the arms, hands and fingers (4). The multifaceted, multisensory input facilitates motor output. The sensory input mechanisms include somatosensory and proprioceptive systems, weight bearing, kinesthesia (the feeling of movement) and visual cues to align the head and the vestibular system to respond to gravity.

The Explorer Mini is designed to promote the proximal support by providing a wide base of support and many points of weight bearing, including the feet, the pelvis, and the forearms. This support and points of weight bearing promote joint stability, and in the case of the upper extremities, can allow for successful distal mobility and use of the joystick.

The Explorer Mini is designed to provide on-time mobility that supports development. As the goal is not simply getting from point A to point B, the proportional joystick and multiple weight bearing surfaces work in concert to bring about postural control and upper extremity stability required for self-initiated movement.

1. Hadders-Algra, M., Brogren, E., & Forssberg, H. (1996). Training affects the development of postural adjustments in sitting infants.        In Journal of Physiology

2. Hadders-Algra, M. (2010) Variation and variability: Key words in human motor development. Physcial Therapy (Vol. 90), Issue 12.        https://doi. /10.2522/ptj.20100006

3. Rosen, L., Plummer, T., Sabet, A., Lange, M. L., & Livingstone, R. (2018). RESNA position on the application of power mobility               devices for pediatric users. Assistive Technology. https://doi.org/10.1080/10400435.2017.1415575

4. Rosenblum, S., & Josman, N. (2003). The relationship between postural control and fine manual dexterity. Physical and Occupational      Therapy in Pediatrics, 23,(4). 47-60.

5. Scheiman, M. (2011). Understanding and managing vision deficits: A guide for occupational therapists (3rd ed.) Thorofare, NJ:              SLACK Incorporated.

6. Westcott, S., & Burtner, P. (2004). Postural control in children: Implications for pediatric practice. PT and OT in Pediatrics, 24, 5-55.

 

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS

Associate Professor in the School of Occupational Therapy at Belmont University

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS is an Associate Professor in the School of Occupational Therapy at Belmont University in Nashville, TN. She has over 40 yrs of OT experience and 20 in the area of Assistive Technology.

She is a member of the International Society of Wheelchair Providers, and the Clinicians Task Force. She is a reviewer for American Journal of OT and guest reviewer for many other journals. She has authored journal articles and textbook chapters in the area of OT and pediatric mobility and access.

 

 

 

 

Benefits of Self-Initiated Mobility in Early Childhood

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Part 2 in our series on early childhood developmental milestones related to mobility. 

Several therapists present courses on the benefits of early self-initiated mobility. We are among them. In this blog series, we are going to begin examining how self-initiated independent movement happens and the developmental milestones that promote independent movement. Self-initiated mobility is defined as movement that is controlled by an individual and may include:

  • Ambulation (e.g., walking, crawling),
  • Use of non-powered technology such as prosthetics, walking aids and manual wheelchairs
  • Use of powered technology such as motorized wheelchairs and battery-operated ride-on toy cars (Logan, Hospodar, Feldner, Huang, & Galloway, 2018).

Powered technology is usually considered when other means of movement have not been successful. The problem with most power mobility devices is they were not truly designed for EARLY. In fact, they are designed for “its really late-but let’s see if we can catch up” and compensate for what has been lost or never gained. Until now we have not been able to observe or examine the full benefits of early self-initiated mobility for young children with disabilities as there has not been a truly appropriate mobility device.

But we do know this, in order to learn, children need SELF-INITIATED exploration:

  • If they cannot bring objects to their mouth, their language may be delayed because the oral muscles are not adequately stimulated.
  • If they cannot bring an object from one hand to the other and manipulate it around their hand, they do not learn size, shape or texture.
  • If they do not crawl or walk or have access to EARLY mobility, they do not learn that their world is a 3-dimensional universe with walls, doors, toys, siblings or parents.
  • If they always have to wait until an adult brings them an object curiosity is not fostered.
  • Crawling (or self-initiated mobility) provides children opportunities to learn about the environment and social relationships, as well as developing their own self-awareness. (Butler, 1991).
  • If children cannot move independently, their visual skills related to spatial relations are delayed.
  • If they do not have self-initiated mobility many aspects of development are delayed.

But if we could explore the true sense of early access to self-initiated mobility, we could better understand the potential to impact development and perhaps change the growth and developmental milestones trajectory for young children with mobility impairments.

 

 

 

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS

Associate Professor in the School of Occupational Therapy at Belmont University

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS is an Associate Professor in the School of Occupational Therapy at Belmont University in Nashville, TN. She has over 40 yrs of OT experience and 20 in the area of Assistive Technology.

She is a member of the International Society of Wheelchair Providers, and the Clinicians Task Force. She is a reviewer for American Journal of OT and guest reviewer for many other journals. She has authored journal articles and textbook chapters in the area of OT and pediatric mobility and access.

 

 

 

 

The Importance of Self-Initiated Mobility in Early Childhood

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This is the first blog in our series on early childhood developmental milestones related to mobility.

Young children are their own change agents. When they want something, they find a way to direct others to provide it for them. They may cry, smile, pout or grimace to cause a reaction to their action. This is a continual, increasingly complex way of making their place on earth their very own. Children learn through exploration. If a child is unable to self-direct their exploration and must rely on others to bring items to them, it is not of their choice.

Children need choice to learn to make decisions, initiate actions and learn reactions.

An infant begins exploring their environment the second they are born. They look around to find the smiling face, put their fingers in their mouth and wiggle any body part they want. If a child is unable to move, they do not find their environment and they may lose their inherent curiosity.

A quick review of development demonstrates how children come to move independently. At around two months of age they lie on their tummy, hold their head up and start to fix their eyes on objects nearby. Once they begin to sit up at 6 months, they stretch out with their hands to find objects within their reach. When successful at finding and manipulating items in reach they begin noticing items beyond their reach and because their arms are not needed to sit up, they reach beyond themselves until they fall on outstretched arms and realise “oh, if I just wiggle the right way I can get that toy.”

This is the beginning of what later becomes crawling which helps to strengthen an infant’s arms and legs to prepare for standing and eventual walking.

But what happens when a young child does not sit unsupported due to a development delay or medical condition that limits their ability?

The typical developmental sequence is altered. Their ability to change their environment, control the objects they want and forage into spaces is halted. What if we could change that? What if we could provide children with a substitute, whether it’s temporary or long term? Wouldn’t it be great if we could provide a device that offers the support a child needs to maintain their change agent status? Permobil recognises the positive impact that creating a mobility solution can have on young children.

The first two years are crucial in development.

The ability to explore the environment ushers in a cascading array of cognitive, social, emotional and spatial skills that concurrently provide tremendous opportunities for growth. Without self-initiated mobility, children are not the agent of change but rather the consequence of someone else’s decision.

Exploration made easy

At only 52lbs, the Explorer Mini is a lightweight, easy-to-transport power mobility device that empowers families and children to explore and learn in home and community environments. 

Learn more

 

 

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Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS

Associate Professor in the School of Occupational Therapy at Belmont University

Dr Teresa Plummer, PhD, OTR/L, ATP, CEAS, CAPS is an Associate Professor in the School of Occupational Therapy at Belmont University in Nashville, TN. She has over 40 yrs of OT experience and 20 in the area of Assistive Technology.

She is a member of the International Society of Wheelchair Providers, and the Clinicians Task Force. She is a reviewer for American Journal of OT and guest reviewer for many other journals. She has authored journal articles and textbook chapters in the area of OT and pediatric mobility and access.

 

Stacey Mullis, OTR/ATP

Director of Clinical Marketing

Stacey serves as Director of Clinical Marketing for Permobil. A practicing OTR for over 20 years, she has experience in school-based pediatrics, inpatient rehabilitation, long term care, and home health. With her interest in wheelchair seating and positioning, Stacey engaged the challenges of providing appropriate seating in various clinical settings. She now uses this experience to develop programs and resources to educate clinicians on the principles of seating and wheeled mobility.

She is passionate about equipping clinicians and through her previous role as Director of Clinical Education with Comfort Company and now with Permobil she has taught nationally and internationally to increase therapist capacity in this specialty area.

 

 

 

Why Everyone Should Be Talking About the Shoulder

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If you are a physio or occupational therapist working with an individual that utilising a manual or power wheelchair, you should have a better understanding of the shoulder than a sports physio. Yes, that’s right you read that sentence correctly. I want us/our client needs us to better understand the shoulder than a sports physio. Why? While that’s exactly what I will explain in today’s blog. 

Whether you are the end-user, therapist, family, dealer/supplier everyone should be thinking about the client’s shoulders. The statistics are staggering. We know that shoulder pain and dysfunction is a problem for all of us in this world, but this becomes even more significant to consider and address if the end-user relies on their upper extremities for mobility. The percentage of shoulder pain in individuals that utilise a manual wheelchair for their mobility ranges from 32% to 78% (1). It’s not just individuals who propel a manual wheelchair that we should be talking about! Even an individual utilising a power wheelchair? Yes! This is because although we like to blame propulsion for all the shoulder pain, this is just one piece. We also have to think about transfers, overhead reaching, loading/unloading a chair into the car, activities of daily living… just to name a few. This is part of the problem, but there is a whole other side to this story that we need to consider. 

What if the individual already has shoulder pain, limited range of motion, decreased strength, or muscles around the shoulder are not fully innervated? How often as a therapist do you assess your client’s shoulder? Are you assessing for pain? Do you quickly run a gross range of motion assessment and then dive further if you see any limitations? Have you at a minimum grossly tested shoulder strength? 

Yes, understanding how the equipment will affect shoulder health is crucial and this is something that I talk about extensively if you have been in one of my courses, but what about how the shoulder at its current state of health and future health will impact the client in the equipment we are selecting? We cannot determine the most appropriate equipment for a client without understanding their shoulder health and we CANNOT assess the shoulder if we do not ask questions and get hands-on. 

This is why we need to know as much or more than the sports physio. We are assessing a shoulder to perform at a high level with activities that the shoulder was not designed for. Now some of our clients may have a fully intact, strong shoulder with no reports of pain similar to an athlete or they may even be an athlete themselves, but many of our clients will have already existing shoulder impairments and pain. It is our job not only to understand what we need to complete in an assessment to determine their equipment selection such as their environment and goals, but we also need to be able to assess and understand a complex shoulder joint and how this will impact our decision. It is a big responsibility, but also one that can really show our level of education, assessment and critical thinking skills. 

So, where do we learn this information? We learned a foundation in our university, but we cannot stop there. We have to continue to further understand the shoulder and how the individual activities of each client affect their shoulders. I would suggest an orthopaedic course on the shoulder. Yes, I know. This may seem like a strange suggestion, but we and the orthopaedic based therapists have a common goal! You could even try to see if you can attend a course that is not in our specific field of study – an occupational therapy course for a physio and vis versa. Some courses allow OTs, physios, chiropractors, etc… these can be great courses to learn not only from the instructor, but also from each other. Finally -Your Clinical Educators! We are happy to help you further your knowledge and can help you to work on integrating the shoulder with the wheelchair and client to achieve the optimal outcome. Join our free webinar on the shoulder on March 24th at 2pm AEDT. If you haven’t registered yet, use the link below to register and begin your further education of the shoulder.  

Click this link to register for our webinar: 

https://attendee.gotowebinar.com/register/591256185888247052?source=Blog 

Finally, remember the why. We are asking our client’s shoulders to work hard, and we need to make sure they are able to handle the demands that we are placing on them. This might include considering a power assist add on to a manual wheelchair, a power wheelchair with ActiveHeight and ActiveReach, or creating a home exercise program to name a few. The statistics are too high. We need to help to decrease this percentage of individuals experiencing shoulder pain and the only way to do this is through education of ourselves and our clients in order to complete a proper assessment and equipment recommendation.

 

Rachel

 

 

International Wheelchair Day and Accessibility

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This week’s blog celebrates International Wheelchair Day and looks into the fundamental concept of accessibility and inclusion.

March 1st 2008 was the first International Wheelchair Day, founded by Steve Wilkinson and has been celebrated on this date every year since. The day has recently gained more traction and provides an opportunity for wheelchair users, their families, friends, support workers and our industry to celebrate the positive impact a wheelchair has in their lives.

The Aims of International Wheelchair Day

To enable wheelchair users to celebrate the positive impact a wheelchair has in their lives.

To celebrate the great work of the many millions of people who provide wheelchairs, who provide      support and care for wheelchair users and who make the World a better and more accessible place    for people with mobility issues.

To acknowledge, and react constructively to, the fact that there are many tens of millions of people    in the world who need a wheelchair, but are unable to acquire one.

Last Friday, our Permobil Asia Pacific President, Bruce Boulanger, and our Australian Customer Service Manager, Graham van Leeuwen, both experienced some of the barriers wheelchair users face by volunteering to spend the day in a wheelchair. In addition to having a firsthand experience in our TiLite manual wheelchairs, they soon discovered additional planning and task adaptations they had to make to enable them to complete everyday activities of daily living and their normal work tasks.

Luckily, both of our volunteers were very familiar with the workplace environment. They knew where the lift was located and how far the bathrooms are from their desks which makes a difference when you’re mobilising in new ways. But what happens when wheelchair users travel to new communities, new environments, and the information about steps, ramps, parking spots and bathrooms is not available?

We often take for granted our ability to move freely within our environments, yet it is this very environment that creates barriers for those experiencing mobility impairments. So for International Wheelchair Day I volunteered to participate in an Australian initiative, Wheel Easy. Wheel Easy is an online platform designed to be similar to Trip Advisor but with specific accessibility information for each landmark.

As well as being International Wheelchair Day, yesterday was also the first day of a series of events called Mapping March for Wheel Easy. The events run in various inner-city areas of Sydney throughout the month of March with a purpose to map as many parking spots, restrooms and leisure spots as possible. Crucially, the platform includes descriptions and photos of accessibility.

Yesterday’s event started with a presentation briefing to all the volunteers. The founders, Justine and Max gave a passionate and inspiring presentation on the website and some insight into their life experiences that motivated the development of the platform. Examples of pictures and types of information that would be useful were discussed and an opportunity to ask questions to the team and the Ambassadors about the types of things to look out for. 

We then loaded the site onto our phones and went out and added cafes, parking and local venues to the website. It was really easy to add the information to each location on the site. The crowd sourcing model also enables anyone using the site to review and update information.

It is an eye-opening experience walking around a new community with a focus on accessibility. Often ramps and entrances are tucked away, accessible parking spots don’t meet everyone’s needs and just because a restaurant says it has an accessible bathroom doesn’t mean it is accessible to all types of impairments. The service uses photos which can assist users in planning what establishments they can patron. The process is also an opportunity to engage in discussion about accessibility with local businesses.

To truly have an inclusive society we need to work towards reducing barriers. Whilst new buildings and communities are more likely to be built to universal standards or building codes that require certain access standards, older infrastructure continues to be more difficult to access and can limit inclusion.

As a wheelchair manufacturer we build and create wheelchairs to enable people with mobility impairments to live full and inclusive lives. However, even when optimal configuration and setup has been achieved the environment can still cause significant barriers. We first aim to ensure that the right fit for the end user and their environment has been met, but we also need to consider that wheelchair users participate in a variety of environments and may require multiple pieces of AT to achieve this.

The first step to breaking down environmental barriers is to create awareness. I challenge readers to create awareness, start a conversation, get involved in an initiative like Mapping March! Let’s keep working towards an inclusive society where barriers are, at the least, minimised.

 

Tracee-lee Maginnity

 

Making Professional Development Opportunities Work for You

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Is it enough to just walk around an expo or attend a clinical presentation, conference or workshop? For me, ongoing development is not so much about meeting the hours required for registration. It is about filling my knowledge gaps and challenging my thinking. If you are just attending to tick off hours you may miss a valuable learning opportunity. Can you relate the new knowledge to a personal development goal? Writing a short reflection will provide evidence of development and assist you to consolidate what you have learned. One of the things I love about seating and mobility is that there are always new challenges and different ways to gain best outcomes. To make the most of any opportunities for ongoing education and development, it is important to be able to identify gaps in your knowledge or skills and seek out appropriate opportunities to meet these goals. Relating any skills or knowledge gained reflectively to enhance your practice will assist with achieving better outcomes for your clients.

 

 

Presenting case studies back to your team is another great way to facilitate open learning and development. For the more experienced clinicians, have you considered submitting at a conference? A case study of an interesting clinical case or a poster presentation is often a great way to start. This is an opportunity to give back to the profession as well as to increase your own skill set. If it’s a bit daunting maybe seek out a colleague to submit together.

Industry Shows

This week our New Zealand team have joined the annual Show Your Ability road show. The Disability Equipment Show travels to 5 cities and provides an opportunity for therapists, end-users and carers to see a range of Assistive Technology from different manufacturers all under one roof. In addition to seeing the newest technology on display, the expo offers an opportunity to see any updates to existing equipment. When I was working as a prescribing therapist I found this expo a chance to ensure I was up to date with what options were available. It’s a great opportunity to get hands on when comparing options. If you are a prescribing therapist, this knowledge can enhance your initial trial process. Attendance can also contribute to your ongoing professional development especially when linked to goals or used to reflectively guide practice. Permobil will be at all venues and we invite you to stop by to say hi and see our mobility and seating options.

 

 

 

Show your Ability Roadshow Expo February/March 2020 (New Zealand)

Monday February 24th - Auckland - ASB Showgrounds

Wednesday February 26th - Hamilton – Claudelands Events Centre

Friday February 28th - Palmerston North – central energy trust Arena

Monday March 2nd - Christchurch - Pioneer recreation and sport centre

Tuesday March 3rd - Dunedin – Edgar Stadium

For more formal CPD opportunities, the ATSA and ATSNZ expos also run simultaneous clinical education streams providing full days of educational sessions and a large industry showcase.

 

 

 ATSA Daily Living Expo (AU) and ATSNZ Expo (NZ)

The Daily Living Expo is sponsored by ATSA (Assistive Technology Suppliers Association). This year the two venues for ATSA are Perth and Melbourne. Swapping locations between Melbourne/Perth and Sydney/Brisbane, ATSA is known for its free Clinical Program which often attracts international presenters. At the time of writing the Perth Program is online and it looks like there are some great presentation on offer! I anticipate the Melbourne program will soon also be available. https://www.atsaindependentlivingexpo.com.au/ 

The New Zealand event equivalent will be held in Auckland on the 8th and 9th of September http://atsnz.org.nz/atsnz-expo/ Rachel and myself will be joining our team at these events to support the education program assist with any clinical questions you may have related to mobility and positioning.

Insert ATSA Banner or photos

International Events

For those wanting to go further afield for some CPD, this year’s International Seating Symposium (ISS) is in Vancouver, but if you’re not booked yet you may want to set this as a goal for next year as it runs March 3 -6. http://www.seatingsymposium.com/

For anyone planning a trip to Europe and wanting to squeeze in some professional development, the European Seating Symposium is held in Dublin, Ireland June 9 – 12. https://europeanseatingsymposium.eu/

Another European conference that focuses on mobility and seated posture is the Postural Management Group, November 2 -4 in Telsford https://www.pmguk.co.uk/conference

If you are new to seating and mobility or you want to further your skills, Permobil currently offers Clinical Education Workshops around New Zealand and Australia. A range of the topics on offer can be found on our website  https://permobil.com.au/permobil-academy/on-site-courses/  We are still finalising the education calendar so the best way to find out about upcoming courses is to subscribe for updates or follow our Facebook pages. If you’re interested in us hosting one of these workshops at your service or in your area reach out to us at Education.au@permobil.com.

Next week we will be introducing the shoulder so don’t miss our Clinical Education Director, Rachel Fabiniak with her blog!

 

Tracee-lee Maginnity

 

 

Using Risk Assessments to Prescribe Cushions?

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Can you use a risk assessment score to identify the best cushion for a user?

Risk Assessment Tools are commonly used to assist in the identification of an individual’s risk factors for developing a Pressure Injury (PI). The Waterlow, Braydon and Norton are 3 of the more well-known and commonly used tools. But can these outcome scores be used to prescribe seating?

Since moving to Australia, I have frequently been asked to match seating solutions to a Waterlow score. Waterlow is a commonly used pressure risk assessment. The Waterlow was designed by a Clinical Nurse Educator, Judy Waterlow in 1985. Its purpose was to assist in student education. The last update to the assessment tool was 2005.

 

In a clinical setting the Waterlow scorecard is used to identify risk. The higher the score the more risk factors for potentially sustaining a pressure injury have been identified. However, it is important to understand that these assessments only highlight risk factors and are not a definitive predictor of injury occurrence.

The collection of information is extremely subjective and has shown mixed inter-reliability in scoring. The information focuses on medical and health information, which is of course valid and recommended to be addressed in the health setting.

However, a risk assessment should only form one part of the clinical reasoning process when determining the best assistive technology solutions to assist someone in addressing and supporting their pressure management needs.This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

 

This is reinforced on Judy Waterlow’s website, “It must be remembered that "Waterlow”, like all risk assessment scoring systems is a simplistic tool. Professional judgement must be used in determining the risk status of the patient/client.” (http://www.judy-waterlow.co.uk/waterlow_score.htm) The Braden Risk Assessment Tool could be seen as even more simplistic which again takes a subjective approach with a health/medical focus.

But when administered by trained health care providers, a Cochrane search found “The Braden scale is the recommended validated and reliable tool for assessing pressure injury risk in critically ill adults.”https://www.cochrane.org/CD006471/WOUNDS_risk-assessment-tools-used-preventing-pressure-ulcers. Cochrane’s overview of risk assessments key message is;  ‘We cannot be certain whether the use of a risk assessment tool makes any difference to the number of new pressure ulcers that develop among people who are at risk. The certainty of evidence ranged from low to very low”, as such I strongly question the appropriateness of selecting a cushion based on a risk assessment score.

 


This is not to say risk assessments don’t play an important role in the prevention and management of pressure injuries. It’s not to say they can’t provide valuable information and direction to addressing the needs of one’s skin and underlying tissue because they can and do. However, they provide us limited information on the assistive technology needs.

 Jennifer Brit, a Canadian OT, developed the Pressure Management Assessment Tool (PMAT)http://www.hsc.mb.ca/files/SSS-PressureMgmt.pdf  I like its comprehensive approach and how it identifies areas where further education or skill training can be implemented as part of a holistic approach. If you are prescribing equipment for people at risk of pressure injury this is another tool you need to consider.

The pressure redistribution surface that’s chosen needs to be the result of the clinical reasoning process. All seating surfaces provide varying levels of immersion and envelopment. A variety of factors need to be considered when selecting the best option for that individual including, but not limited to:

  1. Postural symmetry: Is the user supported in their most functional position. Is the pelvis neutral with even loading through both Ischial tuberosities (Sitting Bones). How will you address this in the seating?
  2. Pressure History: has the user had a pressure injury before? What was the cause? Is this area at risk of reoccurrence? How will you redirect pressure away from any vulnerable areas? Are you using seating with strong evidence-based research guiding its design and use?
  3. Ability to independently reposition and how: Do you need to consider the contours, the fabric, the surface materials or other accessories that could impede? Or is the functional impairment impacting this capacity and you need to consider multi-positional power functions?
  4. MAT – Did a MAT assessment identify any restrictions to range that will impact on seated posture? How can these be addressed to provide best positioning
  5. Functional independence: Will contours or lateral supports support functional capacity or decrease it? What other ways can support be provided?
  6. Cognition / career support: How will equipment and skin be monitored and maintained? The cushions that provide the highest pressure redistribution or setting up a customised cushion require clinical support. Will the end user be able to manage or have the supports in place to assist if required.
  7. History and experience: What did the user previously use? What did they like and dislike about it?
  8. Comfort and seating tolerance: Has the user recently been on bed rest or recently sustained an injury or illness? Do they need something more complex position-wise or is it purely for occasional use? Will the user tolerate the positioning or will it need to be graded? How can the seating position be graded?

Are you trying to load the GTs and let the ITs immerse into a different density foam or fluid or are you trying to maximise overall immersion or loading? Are you trying to decrease direct pressure or sheer forces? Can the cushion do it all …or do you need to consider secondary supports?

There is much to consider when prescribing seating for full time mobility users. When a user has been diagnosed with a Grade 4 or unstageable injury, usual medical recommendation is to stay off it. It is crucial that a multi-disciplinary approach is taken when looking at pressure management.

Although we need specialised seating to support individuals with pressure injuries, specialised seating alone can’t resolve pressure injuries. It is important to incorporate medical treatment and advice into the management plan. In some cases, multiple seating might be required on different seats or for interim use while an at-risk user is building seating tolerance.

Pressure injuries can result in life threatening situations, long term hospitalisation and have a significant impact on independence and quality of life. Risk assessment tools address the health and wellbeing of tissue but do not correspond to development of injury especially in relation to postural positioning and support.

If you’re new to mobility and seating prescription or want a refresher or upskill we have a range of workshops that we run throughout Australia and New Zealand. https://permobil.com.au/permobil-academy/on-site-courses/ We can facilitate these with your local dealer or you can contact us about running clinical sessions for your team.

For further information contact us education.au@permobil.com

 

Tracee-lee Maginnity

 

Travel – Essential AT for Two Different Locations

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In 2019 I was fortunate enough to travel to two very different destinations, Portugal and Thailand. Despite the differences between the two destinations, there are a few pieces of assistive technology that helped me make the most of these two trips.

To begin with, Portugal. Portugal has been on our list of places to go for many years, and in 2019 my wife and I decided to make it happen. As a wheelchair user who has done considerable travel over the years for both business and leisure my strong preference is to pick a place and spend time there rather than spending a night or two at several locations. This saves me the hassle of searching for accessible rooms, packing and unpacking, and hours in transit.

It has the added advantage of letting me get to know one place well, to find places that are often overlooked by tourist guides, to find the best food and cafes, to meet some local people and shopkeepers and to have a better taste of what life is like. In Portugal we decided we would spend our time in Porto.

 

 

For accommodation I used AirBnB. The accessibility filters now in the AirBnB website have worked well for me. We ended up in one-bedroom apartment right in the heart of Porto, equipped with a kitchen, good living room space and a bathroom set up that worked for me. This option was cheaper than the hotels with good accessibility and allowed us to buy the local cheeses, meats, olives, wines and other produce without having to eat out all the time.

 

 

Porto is an ancient city, built around the Douro River. This means there are a lot of steep hills, cobblestones, steps into shops, and at times narrow crowded sidewalk. Not ideal for wheelchairs! But to compensate for this it is a beautiful city, with magnificent views, architecture, history and very friendly locals. In addition, there is some excellent infrastructure such as the funicular, cable cars, accessible buses and accessible paths along the river and on the famous Dom Luís 1 Bridge. We also did a half day river cruise which was spectacular and then caught the train back to Porto (the train stations had portable ramps to get me into and out of the carriage).

 

  

 

In terms of getting around, we explored a lot of the city by wheeling/walking. We used the buses a few times, but mostly we just wheeled/walked to different areas. I find one of the attractions of old cities like this is to just wheel through the lanes and alleyways, get a feel for the history and be surprised by the small shops and their produce.

 

 

 

I will let the pictures and videos do much of the talking regards the beauty of Porto. In regard to equipment, the two vital pieces of equipment were the SmartDrive and the FreeWheel. These two products work so well together, the FreeWheel for the cobblestones and going down steep hills, the SmartDrive for getting up the steep hills. Having travelled through Europe without the FreeWheel, the difference it makes on cobblestones is truly liberating! Having the SmartDrive allowed my wife and I to explore much more of the city than we could of without it.

 

 

 

Moving onto Thailand, this has been one of my favourite destinations for many years. I have found it challenging (I kind of like to be challenged in my travels) but really rewarding. This trip I focused on two areas, Chiang Rai which is a mountainous province in the North West of Thailand famous for the Golden Triangle, and Prachuap Khiri Khan province in South West Thailand. In Chiang Rai I hired a car from the airport, and for the Prachuap Khiri Khan I hired car and drove from Bangkok (about a 4 hour drive). I travel with portable hand controls which can be fitted to an automatic hire car.

 

 

The Chiang Rai area is incredibly beautiful, and I really enjoyed exploring the mountains and the area known as the Golden Triangle. The history of this area is rich and fascinating, and the food is to die for. The influence of different tribal groups, the surrounding countries and the West all make it an intense cultural experience. While not as filled with tourists as the Thai islands and Chiang Mai, there is still reasonable infrastructure.

 

 

The other area I went to, the Prachuap Khiri Khan province, is a beautiful province that is largely unspoilt. The place I stayed in is very close to the biggest national park in Thailand (more jungle than park). It is only about 50 minutes from Hua Hin, a nice seaside village on the coast which is a popular tourist destination. However, where I stayed is far from the hustle and bustle of tourists. It is a new resort, on a river that had otters in it! All the other guests were Thai, I was the only foreigner staying there. Driving there I passed through areas that warned drivers to beware of wild elephants on the road, the bird life is incredible, and the scenery must be seen to be believed.

 

 

Once again, the SmartDrive and FreeWheel played a critical part in my being able to explore these areas. In the mountains of Chiang Rai, the SmartDrive took me to places I could not have got to without it. The FreeWheel allowed me to explore dirt tracks and off-road areas, as well as cross a suspension bridge that had big gaps in the planks.

If you’re interested in any more details regarding these two trips, please don’t hesitate to contact me. I hope wherever your travels take you in 2020 you have a great time!

 

Malcolm Turnbull

Senior Advisor and Ambassador

Mal - 40 years a para’ 

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40 years ago, in the late hours of January 6th, 1980, I was a passenger in a vehicle that went over a 20-metre cliff. After a long wait to be found and rescued, I arrived at Coffs Harbour Hospital with a broken rib, a punctured lung and a deep knowing that something was significantly wrong. Not long after receiving my x-rays the local doctor came with the news that my spine was severed at T5 level, complete, and that I would never walk again. It was a short conversation, in retrospect a blunt statement of fact that I remain grateful for. The full impact of this life changing event would unfold over the years and continues to unfold as I enter into my 60th year. 40 years, two thirds of my life, as a wheelchair user.

There is much I could write about my experiences in Prince Henry Hospital and the following years, enough to fill a book. But today I want to reflect on some of the changes that have happened over the past 40 years. 

There have been obvious changes in the quality and range of Assistive Technology available. My first wheelchair was a chrome plated folding frame wheelchair that weighed around 24kg. It was an “off the shelf” chair, it was so big I “swam” in it. Pioneers in modern wheelchairs, the likes of Michael Callahan, Nick Morozoff, Marty Ball and Mike Dempsey (all wheelchair users) paved the way for the amazing range of manual wheelchairs available today.

The advanced technology built into powered wheelchairs that allow for even the most mobility challenged users to not only get mobile, but to be able to do so in various seating/standing positions and with maximum comfort. Improvements in seating and positioning products, pressure care cushions and support surfaces, motor vehicle modifications and control options, off road devices – power assist was not even a concept in the 1980s. 

Environment control systems were starting to appear in the late 1980’s but they cost tens of thousands of dollars and required specialised systems and installs. Now off the shelf devices from mainstream companies are doing more than could ever have been imagined. Add to that the robotics that are in their relative infancy. I find the range of Assistive Technology available today mind boggling, and it is hard to imagine what will be happening in 40 years from now!

Apart from Assistive Technology, facilities for, and attitudes towards, people with disabilities have vastly improved. In 1980 I could access three railway stations in Sydney, there were no building regulations for accessibility, accessible toilets were few and far between and I can’t remember being able to book an accessible hotel room. In my first few years as a wheelchair user, I was referred to doctors in Macquarie Street, Sydney for specialised assessments – and all of their rooms were upstairs! I had to get out of my chair and “bum” it up the stairs, towing my chair behind me.

In 1981 the United Nations General Assembly proclaimed the first International Day of People with Disability which called for a plan of action at the National, Regional and International levels, with an emphasis on equalisation of opportunities, rehabilitation and prevention of disabilities. The theme of IYDP was "Full Participation and Equality", defined as the right of persons with disabilities to take part fully in the life and development of their societies, enjoy living conditions equal to those of other citizens and have an equal share in improved conditions resulting from socio-economic development. This accelerated awareness around disability both here and internationally.

In 2000 the Paralympics were held in Sydney, which really helped push improved accessibility. There is still a lot of work to do, here in Australia and internationally (especially in underdeveloped and developing countries) but it is a huge improvement from the 1980s.  

There have also been improvements in the attitudes towards people with disabilities. I remember when I first left hospital I would go to my local pub for a beer and people would walk past and drop a $2 dollar note on my lap (yes, we had $2 notes!). People asking my companion what I would like to eat instead of asking me, pushing my chair despite my protests, the most inappropriate questions, hushed whispers of pity and amazement that a wheelchair user could drive/work etc. It was not all bleak, of course, there were lots of fantastic people – like the staff at Ultimo UTS who made major adjustments to allow me to study Mechanical Engineering. But there was a general level of ignorance around disability that has improved greatly.

Again, there is a lot more to be done. People living with disabilities in Australia have high levels of unemployment, and there is still a degree of ignorance and fear around how to interact with people who live with disabilities. However, overall the understanding about people with disability has improved hugely. This is also reflected in the language used. Largely gone are terms such as “cripple”, “handicapped”, “retarded”, “disabled”, (although the “Disabled Bathroom” still gets a run – who wants to use a bathroom that is disabled?). In a recent trip my wife and I did a stop-over in Dubai and came across a sign referring to people with disabilities as “People of Determination”. My mum always said I was a determined little so-and-so.

Another thing that has changed dramatically is funding for people with disabilities. In 1980 you were either fortunate enough to be eligible for compensation (eg. from car insurance or worker comp) or you fell into a state-based funding scheme such as Enable. I vividly remember being in Ward 1 at Prince Henry Hospital and hearing compensation lawyers advise other inpatients to avoid work before their compensation case because this would reduce their “loss of income” payout. The compensation cases would often drag out for many years, by which time many people found it extremely difficult to return to the workforce.

The implementation of iCare Lifetime Insurance in NSW, and similar no fault insurance schemes in other states, was a big step forward but it still created a two tiered approach to care – those in the iCare scheme had access to the best equipment and care available while those in the public schemes had access to basic equipment and care. The implementation of the NDIS has been a major reform and is potentially the world leader in provision of services and equipment for people with disabilities. Again, it is not perfect and the lack of uniformity across the nation is frustrating, but it is a huge step forward and at its core embraces principles of empowerment, inclusion and participation for people with disabilities.

There is so much more that can be written, and I am sure others would have lots to say about this. Disability Advocacy groups such as The Quadriplegic and Paraplegic Associations, NSW Physical Disability Council, CPAs – so many great organisations – have made and continue to make a positive impact on the lives of people with disabilities. Medical developments, from the ambulance and first responders to the fundamentals of bowel and bladder care to advanced scanning and medical procedures have made a huge impact. Research into best practise for therapists and clinicians, the expertise and professionalism of Assistive Technology suppliers, access to travel and sports – the ground-breaking Sargood on Collaroy facility – the list goes on. 

Finally, I want to acknowledge the generations of end users that have paved the way for people with disabilities – passionate and forward-thinking wheelchair users like Mark Bagshaw, Chris Sparks, Nick Morozoff, Errol Hyde, Kevin Coombes, Kurt Fearnely and many more.

 

Malcolm Turnbull
Senior Advisor and Ambassador