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As clinicians, there are elements of education interwoven within many of our roles, teaching foundation skills or ways to use assistive technology to enable engagement in activities of daily living for example. An OT undergraduate program includes learning about how people learn and techniques to assist in the learning process.

Within the wheelchair and mobility prescription role the prescribing therapist is not just an assessor. The assessment, trial and clinical justification/funding report are all an integral part of the role but the delivery and teaching of how to use and maintain the device is also part of this scope and relative to the end user’s lived experience. Whilst the delivery of Assistive Technology (AT) may signal the end of the process for the health professional, it is often the beginning for the end user, especially if it involves a new piece of AT.

 

 
The Clinician as an Educator

Within the assessment process you may identify that an end user is struggling with a transfer. Task analysis may guide you to consider trialling a new feature within a mobility base to assist in this task. The trial may show that this feature is indeed functionally beneficial but may also identify that the task requires further adaptation. Based on the end user’s experience, functional capacity and support requirements, they may require help in task adaptation or it may be as simple as providing guidance in learning how to operate the feature and the task adaptation will develop from ongoing use.

Support workers may need to be taught how to operate the mobility base or position it appropriately for a hoist transfer. Whilst there are similarities in operational access between wheelchairs, there are also variances. Those supporting the task also need to learn how the equipment works and the specific way it will be used for the individual end user.

 

 

While literature discusses multiple different learning styles, there continues to be debate around the ideology of learning styles. Do we have a specific style that we learn best from or is it the content of the learning matched to the style?

We do know people learn in different ways. Riener and Willingham’s article, The myth of learning styles (2010), argues that there is no credible evidence that learning styles exist. Further, they argue that learners differ in their ‘abilities, interests, and background knowledge, but not in their learning styles’.

Other academics, such as Richard Felder, believe that while learning styles do not provide a complete portrait, they can potentially provide an outline or framework. However, addressing learning needs is infinitely more complex than implied by learning styles ideology.

Less debated is that we use a combination of styles when learning. The three most cited learning styles are: Visual, Auditory and Kinaesthetic and we may use one or a combination when teaching. A quick reminder, or for readers not familiar with learning styles:

Visual learners: who prefer images, pictures, diagrams, films and videos or demonstrations.

Auditory learners: who learn best through the process of listening.

Kinaesthetic learners: who learn by doing.

Let’s consider the delivery of a wheelchair. It’s the first wheelchair for a gentleman with a progressive neurological condition. He is still walking but experiencing falls. His wife is struggling with the sudden and rapid changes going on. Neither has any experience with a wheelchair but both understand that with his falls lately it will be best to use one. The wheelchair will be initially used for community access. We could just talk through how to disassemble the chair to put it into the car trunk. We have told them how to do it, we even remind them that they must disengage the wheel locks before removing the wheels…is this enough?

Most of you would combine this with a demonstration. But to ensure understanding and that they can manage the task, many of you would also get the client and his wife to have a go at doing it. The value in this is that you can ensure they can do the task but also the kinetic hands on learning this offers. The “doing” is important as the task involves doing a new activity with a new piece of equipment and will impact on the ability to use the chair in the community.

For more complex equipment training or where multiple carers are involved, you may have developed resources to assist in the facilitation of learning such as photos of equipment or positioning.

 

 


The Clinician as a Learner

We often put thought into the best techniques and styles to support learning for clients but do we also apply this to our own learning opportunities? Continuing Professional Development (CPD) requires us to complete hours of ongoing learning. We need to make these hours as beneficial as possible, so as well as matching content to our learning goals it is also important to consider the delivery of the content and what will best work for you. For me personally, I like to get hands on with equipment to understand its adjustments and capacity especially when it’s a new piece of equipment I haven’t previously worked with.

2020 has brought new challenges to ways of working and learning. We know how important ongoing professional development is and so in March this year we increased our bi monthly webinar program to bring a new live webinar every week. This was a great way to continue to offer theoretical concepts as learning opportunities however makes it more challenging in some areas. Therapists at workshops who are new to seating assessments have consistently said how beneficial doing and having the assessment done for them can be.

Applying case study concepts to hands on experiences with equipment is also very highly rated in the clinical workshops. But following social restrictions and recommendations has unfortunately limited these opportunities within countries globally.


O2O and Education Opportunities

This month we are excited to be launching our very first Online-2-Offline (O2O) event. This form of learning begins with an online component led by our Clinical Education team, followed by a hands on session with your local experienced sales team to enable you to apply clinical learning in a practical and supportive environment. The education team will remain online throughout the event to answer any questions.

This format has already proven successful with fantastic feedback from both our Chinese and Australian markets. You can hear a bit more about this event below.

 


 


 

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.

 

 

Last week we looked at ISO standards – the history behind these and how they apply to wheelchairs.  This week we are looking at one particular standard – ISO 7176-19:2008 - Wheeled mobility devices used as seats in motor vehicles.  This standard is similar to the ANSI/RESNA WC19 standard, the recommended standard in North America, often referred to as WC19.  The standards surrounding wheelchairs and their safety for use as seats in vehicles is something therapists need to be aware of when prescribing wheelchairs for those who need to remain seated in their wheelchairs when traveling in a vehicle.  The ISO 7176-19 is deemed the minimum standard for wheelchairs that are used as seats in vehicles, while the ANSI/RENSA WC-19 has additional components to optimise wheelchair users safety. 

When we purchase a vehicle, we are presented with information as to how safe that car is likely to be in the event of an accident, for example a particular car may have an ANCAP (Australasian New Car Assessment Program) star rating telling us how well the car performed under crash testing, with a five star rating being a safer vehicle.  Manufacturers reduce the risk of death and injury in motor vehicle crashes using a systems approach to occupant protection, in which the vehicle, the vehicle seat and occupant restraint system (ie seat belt) each to contribute to a safety system. 

For wheelchair users who remain seated in the wheelchairs while travelling in their vehicles, a similar systems approach is also used, incorporating the wheelchair restraint system in the vehicle, the wheelchair and seating itself, and again the occupant restraint system. 

The wheelchair restraint system and the occupant restraint system are installed into vehicles by a person certified to complete the modifications to the relevant standard, with the modifications completed being appropriate to the wheelchair used – for example use of a hoist and tie down system that is rated for the type of chair used, with a power wheelchair requiring different specifications to a manual chair. 

The safety of wheelchair users while travelling in a vehicle is dependent on the wheelchair restraint and seat belts being used appropriately, for failure to do so can result in injury in situations where occupants seated in the standard vehicle seat may not be harmed at all.  Potentially a wheelchair that is not restrained properly in a vehicle can tip over if the vehicle turns sharply, or a seat belt that is not applied correctly can mean the occupant can come out of their seat and injure themselves on the interior of the vehicle if the vehicle stops suddenly.

Photo 2 source https://education.nsw.gov.au/public-schools/astp/contractors/safety-requirements

The use of these restraints is complemented by use of a wheelchair that meets the ISO7176-19 or WC19 standard to reduce the risk of injury to the end user.  The test for this standard is to subject the chair a forward facing crash test at 50km/hr with a 70kg crash test dummy.  This test is typically tested with the seating system associated with this chair, however after market seating products can be tested by the WC20 standard to establish their safety under crash conditions.  Chairs that meet the WC19 often use tie down points on the chair, these being four permanently labelled, easily accessible securement point brackets, however docking systems such as Ezi-lock and Dahl are also an option for some users.  Other aspects of the ISO 7176-19 and WC19 standards include use of seating systems that allow the seat belt to be positioned effectively and that there are that there are no sharp edges on the chair that may cause damage to either tie down points or the vehicle occupant restraint system. 

A person remaining in their wheelchair seat is often seen as a convenient means of travel, however use of the vehicle’s standard seat is considered the safest option for a person to travel.  Prior to considering vehicle modifications, questions to consider are 

  • How well can the person transfer in/out of their wheelchair?  Can they safely transfer into the manufacturer installed car seat? This may involve use of a mobility vehicle to allow the person (and their chair) to be transferred up into the vehicle, where they can then transfer into the standard car seat and their chair be restrained for unoccupied travel. 
  • For young children, or those who require assistance to transfer, the risk of injury to the carer when transferring the child/person in/out of the car seat needs to be weighed up against the risk of travelling in the wheelchair – where for many people, the risk of injury during the transfer outweighs the potential risk from travelling in their wheelchairs. 

If travelling in a wheelchair has been established to be the safer solution for the end user, considerations for the wheelchair include 

  • What standard has the chair been certified to?  Has the chair been certified for occupied travel?  Some chairs are only certified for un-occupied travel, meaning it is not intended that the end user remain in the chair while travelling in a vehicle.  Information as to what standard the chair has been tested to is included in each chair’s user manual, or can be obtained from the dealer or supplier. 
  • If a docking system is to be used, has the docking system been tested for the model of chair you are considering?
  • Chairs that are custom built, eg custom manual wheelchairs, may not be certified for crash testing, but may have the features that the standards recommend.  The benefits and challenges of these chairs need to be discussed with the end users to ensure that they are making an informed choice about the crash testing status of these chairs.
  • The pelvic positioning belts and/or harnesses used as positioning aids on the seating system are not intended for use as a vehicle restraint, although may be used in addition to the vehicle restraint system to ensure the user maintains an optimal position while travelling in their vehicle.
  • While travelling in the vehicle, ideally the end user requires access to a head support to prevent injury to their neck in the event of an accident.  For some users, this may be installed as part of the vehicle modifications (eg for those driving their vehicles) however others may require a head support attached to their chair as part of their seating system.  When the head support is attached to the wheelchair, consideration needs to be given to how it is mounted – for example if mounted to the back support, the back support needs to be of sufficient height for the mounting to be effective.  

When the wheelchair is in the vehicle 

  • The wheelchair needs to be restrained using the appropriate restraint system – for example use of tie downs attached to the identified tie down points on the chair.
  • The person travelling in the wheelchair then also needs to be restrained using a certified three-point belt, to ensure they remain in their chair in the event of an accident.  Some wheelchair manufacturers offer the ability to fit a vehicle certified hip belt that a shoulder belt may attach to in a vehicle for ease of fitting. 

A person being able to use their wheelchair as a seat in a vehicle can be the difference between being able to access the community or needing to stay home, and use of standards can help keep wheelchair users as safe as possible while travelling in their chairs.

   


For further information please see

ANSI/RESNA WC19 - http://wc-transportation-safety.umtri.umich.edu/crash-tested-product-lists/wheelchairs

RESNA Position Statement on Wheelchairs used as Seats in Motor Vehicles - https://www.resna.org/Portals/0/Documents/Position%20Papers/RESNAPositiononWheelchairsUsedasSeatsinMotorVehicles.pdf

Vehicle modifications

Mobility Engineering Australia - https://www.mobilityengineering.com.au/

Low Volume Vehicle Technical Association - https://www.lvvta.org.nz/documents.html#standards

Safety Ratings of Motor Vehicles - https://rightcar.govt.nz/safety-ratings 


 

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.

ISO standards are a term many of us have heard of, and will be influenced by in our daily lives, but potentially do not know much about.

ISO is an independent, non-governmental international organisation, with membership of 164 national standards bodies.  The name ISO is derived from the Greek ‘isos’ meaning equal, with the name ISO being used in all countries around the world, regardless of what language is spoken.

ISO standards started with the essential question: what is the best way of doing this?  The first meeting to discuss international standards was in London in 1946, where 65 delegates from 25 countries met to discuss the future of International Standardisation, with ISO officially coming into existence in 1947 with 67 technical committees.   Today ISO is based in Geneva, Switzerland, with membership of 164 national standards bodies, 792 technical committees and sub-committees and over 23000 standards. 

Each technical committee is made up of independent experts nominated by ISO members, with the goal of each technical committee being to look at products and services with an eye towards ensuring safety, quality, reliability and effectiveness. 

Today the standards cover almost all aspects of technology and manufacturing, with each standard being drafted by a technical committee (TC) or sub-committee (SC) and taking approximately three years to confirm.  Each international standard is reviewed at least once every five years by all ISO member bodies, with the relevant TC/SC deciding whether the standard should be confirmed, revised or withdrawn.  Testing for each standard is reviewed by the technical committee to ensure they are appropriate and reasonable for a test lab or manufacturer to be able to apply, but also that they are meaningful for the end user.  Each standard is not intended to endorse specific solutions, just allow for a direct comparison of specific properties

ISO standards are present behind many aspects of our home and work lives, from the food we eat, the shoes we wear, the toys our children play with, the paper we use in our printers or the credit card we can use around the world.   One of the most popular standards is ISO 9001, this standard sets out the requirements for a quality management system, helping businesses and organisations be more efficient and improve customer satisfaction. 

ISO standards can also facilitate manufacturers working together to produce solutions that make our daily life safer and more convenient, for example, the use of ISOFIX to secure child car seats in vehicles.  Use of child car seats in vehicles is a solution that increases a child’s safety while travelling, however installing these car seats can be a challenge.  ISO 13216-1 relates to the the universal system for anchoring child restraint systems to vehicles, with the purpose of improving the safety of child restraints by making the installation of these seats easier and more reliable.  This standard has resulted in many car manufacturers installing ISOFIX anchor points in their cars (a metal loop hidden in the gap between the flat and upright parts of the seat) and child car seat manufacturers producing a product that installs into these anchor points.  For parents, using ISOFIX provides reassurance that they can install their child car seat correctly to maximise the safety benefits of the seat.  (This was a system that I used with both of my children and had no idea where the name derived from!) 

How does ISO standards relate to power wheelchairs?   The technical committee responsible for wheelchair standards is ISO/TC 173, Assistive products for persons with disability.   ISO/TC 173 was created in 1978, with the scope of standardisation in the field of assistive products and related services, to assist a person in compensating for reduced abilities.  This committee has developed numerous standards for persons with disability ranging from aids for ostomy (surgical opening for discharge of waste) and incontinence to assistive equipment helping people with a visual impairment use pedestrian crossings, to hoists for transferring.

From ISO/TC 173, Subcommittee SC 1 relates to wheelchairs.  This group is responsible development and maintenance of the ISO 7176 series, a 32 part series covering items such as static and dynamic stability, effectiveness of brakes, impact and fatigue strengths, obstacle climbing ability and wheeled mobility devices for use as seats in motor vehicles.

Each part of the standard is accompanied by a document that specifies the test methods and requirements for determining specified standard, for example ISO 7176-30: 2018, also known as Wheelchairs – Part 30: Wheelchairs for changing occupant posture – Test methods and requirements.  These guidelines specify the test methods and requirements for determining the safety and performance of a wheelchair that incorporates technology to alter the posture of the wheelchair user, for example a power wheelchair that offers power standing.

How do you find out what chairs have been tested to what standard?  The user manual of the chair will state what standards and regulations the chair meets the requirements of, including whether it has been tested to the ISO 7176 series.  Alternatively, the supplier or dealer who provide the chair should be able to tell you. 

This testing is often a big point of difference between high and lower cost power mobility options.  Mobility solutions that are lower cost are potentially manufactured from inferior materials or with an inferior design, where typically their user manuals will make little (or no) reference to any ISO testing.  This isn’t to say these mobility solutions are a poor choice, for a low cost mobility device may work well as a useful adjunct to a person’s mobility, for example a basic mobility scooter to allow a person to mobilise around a shopping mall independently.  However, this same device may not be safe or durable for a user who is dependant on a mobility device for their all-day mobility across multiple environments.  These users require a mobility solution that has been tested to ensure it is a safe and reliable device for everyday use, with ISO standards providing an independent means of establishing this. 

Next week we will take a closer look at ISO 7176-19:2008 - Wheelchairs Part 19: Wheeled mobility devices for use as seats in motor vehicles.  We will look at what parameters this standard tests and what other factors need to be considered when a person is using their wheelchair as a seat in a vehicle.


References

https://www.iso.org/home.html

For more information on ISOFIX https://youtu.be/W0sTvpyKgKY


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.

 


September is a busy month of awareness days and activities, this week we are taking a look at STEPtember, a health and well being fundraising event in support of cerebral palsy.  STEPtember is an annual event held throughout the world to raise funds for cerebral palsy (CP) research and services, with the goal for participants to walk, swim, ride, wheel or spin their way to 10,000 steps per day for 28 days. 

Currently there are 34,000 people living with CP in Australia and approximately 10,000 people in New Zealand.   STEPtember is usually held in both Australia and New Zealand, however this year only Australia are participating due to COVID-19 related issues in New Zealand.

The funds raised from STEPtember support a wide range of services provided by the Cerebral Palsy Alliance (Australia), the ultimate going being to help people living with CP to live their best lives.  Initiatives highlighted for this year’s STEPtember campaign include identifying babies at risk and providing early intervention, supporting children with disabilities, and their families, in regional and remote areas, supporting access to sport programmes, and providing equipment and technology solutions.  One interesting project that may benefit more than those living in Australia is support of stem cell research, with researchers investigating stem cells as a possible treatment for CP.

Stem cell treatment is a complex topic.  Stem cells are grouped depending on the number of tissues they can be differentiated into (cited in Eggenburger et al 2019) with different stem cells obtained from different sources.  For stem cell research in the treatment of CP, the source of stem cells is typically umbilical cord blood or bone marrow.  These stem cells may be collected from the same person (ie stem cells used from an umbilical cord that had been stored, with the child receiving their own cells at a later date) or from a different person (ie a donor).  Use of umbilical cord blood or bone marrow has previously been limited to blood or immune disorders, however in more recent years, research is showing that it may also be of benefit in treating various neurological diseases (cited in Eggenburger et al 2019).

A systematic review and meta-analysis completed by Eggenberger et al, reviewed and combined the results of five studies, and suggested that stem cell treatment may result in an improvement in gross motor function with those diagnosed with CP, however the number of variables in the studies  makes establishing the size of the treatment benefit challenging.  One of the studies included was one by Sun et al, this study was more specific in the age of the children involved in the study (1 to 6 years) with all children receiving stem cells from their own, previously stored, umbilical cord blood.  The outcome of this study was interesting in that both groups of children (control and intervention groups) improved more than expected in their gross motor abilities (measured by the GMFM), highlighting that other treatment interventions were also working, and that those who received a larger dose of stem cells showed more improvement.  These studies highlight the need for further research into the topic, to establish what stem cells are more effective, and at what dose and at what age. 

Another project, identifying babies at risk, is important as research has shown that babies who have CP can be identified at a young age.  The systematic review completed by Novak, Morgan and Adde identified that a diagnosis can be accurately made before six months of corrected age, using magnetic resonance imaging and standardised assessments such as the Prechtl Qualitative Assessment of General Movements, and while the severity of the CP is more challenging to establish, early diagnosis allows the family and therapy team  to optimise infant motor and cognitive learning, as well as prevent secondary complications and enhance carer well-being. 

Overall, advances in diagnosis, prevention and treatment now mean that the incidence of CP is falling, and of those who are diagnosed, more children than ever will walk (Novak et al 2019).   In high income countries, two in three individuals diagnosed with CP will walk, three in four will talk and one in two will have normal intelligence (Novak 2017)

STEPtember also highlights the importance of movement in general, with the different ways people move highlighted in their choice of STEPtember trainers, from independently mobile, to mobile with a walking frame to mobile in a manual or power wheelchair.  Use of assistive technology can allow a person diagnosed with CP an efficient method of mobility, and potentially maximise their ability to participate in activities such as STEPtember, but also maximise their participation in family and school life. 

STEPtember offers a novel means of fundraising that is likely to benefit everyone who participates, and it is well timed so that participants can head into the warmer months happy and healthy following a bout of regular exercise.  While many of us may have missed the chance to officially join STEPtember, it isn’t too late for us to check out the STEPember website and jump on the bandwagon and getting moving!

For more information about STEPtember please see https://www.steptember.org.au/home 


References 

Eggenberger S., Boucard C., Schoeberlein A., et al  (2019) Stem cell treatment and cerebral palsy: Systemic review and metaanalysis World Journal of Stem Cells 11(10) 981-903

Sun J.M., Song A.W., Case L.E. et al (2017) Effect fo Autologous Cord Blood Infusion on Motor Function and Brain Connectivity in Young Children with Cerebral Palsy: A Randomised, Placebo-Controlled Trial Stem Cells Translational Medicine 6:2017-2078

Novak I., Morgan C., Adde L., (2017) Early, Accurate Diagnosis and Early Intervention in Cerebral Palsy, Advances in Diagnosis and Treatment. JAMA Pediatr. 171(9): 897-901

Novak I., Morgan C., Fehey M., et al. (2019) State of the Evidence Traffic Lights 2019: Systematic Review of Interventions for Preventing and Treating Children with Cerebral Palsy.  Current Neurology and Neuroscience Reports 20:3


 

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.

 

 


Monday 7th September marks Duchenne Muscular Dystrophy (DMD) awareness day in both Australia and New Zealand, a global day to raise awareness of those affected by Duchenne and Becker Muscular Dystrophy (BMD).

DMD and BMD are both X-linked recessive disorders, caused by mutations in the dystrophin gene.  This mutation can be caused by a certain part of the DNA being doubled or changed, or be missing altogether, meaning the gene will not work as it is supposed to.  DMD and BMD can be passed down from a mother who is a carrier, or the gene can mutate spontaneously, and occurs in all ethnicities around the world.

The difference between Duchenne and Becker Muscular Dystrophy?  The dystrophin gene encodes the protein dystrophin, which is essential to healthy muscle growth and functioning.  Duchenne patients have a complete lack of the gene that produces dystrophin, while Becker patients have lower levels or a shorter version of the protein.  People diagnosed with Becker Muscular Dystrophy have less severe symptoms that often show later in life. 

Looking specifically at DMD, DMD affects between 1 in 3500 and 1 in 5000 live male births globally.  Affected boys become symptomatic at 3-5 years of age due to proximal muscle weakness, presenting with difficulties with running, more frequent falls and difficulty rising from the floor.  DMD is characterised by a well-known progression, including loss of mobility, reduced range of movement, development of deformities, and reduced independence with activity of daily living tasks. 

Introduction to Duchenne Muscular Dystrophy from World Duchenne Awareness Day on Vimeo.

At this stage there is no cure for DMD, however gene therapy offers potential for future treatment options.  The gene for DMD was one of the first genes discovered, however therapy options are proving challenging due to the range of causes of the mutations that result in DMD.  This range of causes means that one single gene therapy will not work for everyone diagnosed with DMD, however research is ongoing. 

A treatment option that is now well established is the use of corticosteroids.  Corticosteriod use is recommended by the current DMD care standards to start at around 4-6 years of age, and while the exact mechanism as to how they work is currently not well understood, evidence as to their benefit is being demonstrated.  Koeks et al reviewed data collected through the TREAT-NMD global DMD database, identifying that corticosteroid use is common in boys until the age of 14.  For those who had taken steroids, 79% were still ambulant at the age of 10, compared to 52% of those who had not.  The median age when a boy was unable to ambulate in non-steriod treated group was 10 years old, compared to 13 years in the steroid group.  Corticosteroids also significantly reduced the number requiring scoliosis surgery, the need for assisted ventilation and a lower incidence of cardio myopathy in those aged over 20 years of age. 

Another important aspect of therapy is promotion of daily stretching, particularly of the lower limbs, and use of positioning and equipment to prevent development of contractures and deformities.  The DMD Care standards reinforce that stretching needs to begin before loss of range of movement, and to initiate a standing programme using a standing device or wheelchair with upright positioning in the early non-ambulatory stage

This links to a current topic of conversation around the use of power standing wheelchairs for those diagnosed with DMD, with the chair being available for use as walking ability is lost. Research to support use of power standing chairs is currently limited, however evidence is emerging to support their use.  

Bayley et all explored the effect of power standing chairs on range of movement and pain in adolescents with DMD over a 20 week period, and suggested that joint range of movement was preserved during the study period, including a potential increase in hip flexor length, despite a progressive loss of ambulation.

In a qualitative study by Vorster, Evan and Murphy et al,  ‘Capacity to be able’ was the central theme that emerged from the data collected, with provision of a power stand up chair coming at a time when gross motor skills were declining.  A number of benefits were observed with the use of power standing chairs, including participating in school activities that were usually done in standing, such as art or science, to independence with personal care tasks such as toileting and brushing teeth.  More autonomy with participating in activities is considered important for adolescents and appeared to be associated with a strong emotional wellbeing.  An important finding of the study was that individuals who received the power stand up chair after becoming non ambulatory appeared to gain less benefit, highlighting the need for timely provision of power stand up chairs for this group.

Access to power standing chairs for those diagnosed with DMD can be variable depending on the experience of the wheelchair and seating therapist and the funding systems available.  While a power standing chair is not going to be suitable for all adolescents diagnosed with DMD, there is a group that have the potential to maintain a reasonable level of independence and well being if provided with one – at the right time.  The use of corticosteroids now means that boys are now entering adolescence when they lose the ability to walk, and are at an age typically associated with increasing independence.  Provision of a power standing chair will allow these adolescents to gain the therapeutic benefits associated with standing, in particular maintaining range of movement in their lower limbs, as well as maintaining independence in meaningful tasks at home and at school.  While these benefits are in no way a cure for the underlying muscle weakness associated with DMD, it may allow this generation of boys and adolescents with DMD to make the most of the adult life that advances of technology are gradually giving them.

 


Save Our Sons Duchenne Foundation https://www.saveoursons.org.au/ 

Muscular Dystrophy New Zealand https://www.mda.org.nz/ 

Standards of Care for Duchenne Muscular Dystrophy https://vision-dmd.info/revised-standards-of-care-for-duchenne-muscular-dystrophy/  

References 

Koeks Z., Bladen C.L., Salgado D., Clinical Outcomes in Duchenne Muscular Dystrophy: a Study of 5345 Patients from the TREAT-NMD DMD Global Database (2017) Journal of Neuromuscular Diseases 4 293-306 

Vorster N., Evans K., Murphy N., et al (2019) Power standing wheelchairs promote independence, health and community involvement in adolescents with Duchenne muscular dystrophy. Neuromuscular Disorders 29, 221-230 

Bayley K., Parkinson S., Jacoby P etc al (2020) Benefits of power standing wheelchair devices for adolescents with Duchenne muscular dystrophy in the first year of use. Journal of Paediatrics and Child Health 


 

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.

Preventing Pressure Injuries Outside the Wheelchair

 

Last week Australia was encouraged to create awareness around chronic wounds as part of Wounds Awareness week.

This week it’s New Zealand’s turn to promote awareness with their Wound Awareness week running this month. As such we will continue our theme of Pressure Injury (PI) prevention and redistribution surfaces in this week’s blog.

Good Pressure Injury (PI) risk reduction requires us to consider all the support surfaces being used. We can apply many of the same principles of design, forces, and materials science to multiple surfaces and positions to specifically address potential equipment risks. Today’s blog, whilst still addressing reduction of risk of PI, will look at some of the other positions and surfaces that we need to consider. 


Lying

End users that are dependant on carers for transfer assistance can spend increased time in bed based on the availability of support staff. Whilst this is not ideal it is the reality for many with mobility impairments. This can result in an increased need to complete functional tasks in bed and for the user to use the bed functions such as head raise to enable seated tasks.

Although this bed function can assist someone to complete tasks in bed, we need to acknowledge the shear forces that accompany this bed movement. Using a knee break in conjunction with head raise can reduce the amount of slide but not eliminate the risk of sustaining a shear sacral injury. We also need to consider the mattress surface and how it will interface with the user and the bed profiling.

As with sitting, those that have significant movement limitations will be at a higher risk of sustaining an injury due to lack of movement. For these users the mattress materials and design can be crucial.

A ROHO Mattress Overlay

When we think about the materials that provide the highest levels of redistribution the first thought is air. When air is used in a container that enables it to work as a fluid, we are considering hydrostatic forces rather than peak forces, this enables maximum immersion and envelopment. A benefit of a non-powered air mattress is that there are no power chords as potential trip hazards or risk of power outage impacting the usage.

Other commonly prescribed air mattress options include air alternating systems. These work on the concept of loading and off-loading. These systems usually consist of rows of tubes that inflate and deflate in sequence so that there are times when the depressed cells mean there is no contact on the corresponding area of the body. As such the peak pressure increases when the cells are inflated. This constant changing can make some users feel like they are on gentle waves like water. 

Talley Quattro Acute Mattress Replacement

When considering air alternating systems, you do need to check the minimum user weight requirements as this differs between manufacturer design as does the sequence or ratio of inflated cells. For some users the inflation of cells may not be tolerated. Another point frequently raised by users is the noise of the power unit; whilst most manufacturers have significantly reduced the noise we need to consider the impact even a small noise can make in the quiet silence of the middle of the night….many of us have experienced that dripping tap you may not hear until you lie awake trying to sleep!!

Consider the location of the users home, some areas are known for power cuts and a contingency plan may be required for what to do in the event of a power outage, this may include consideration of a generator in some remote locations.

With both types of air mattresses we do need to consider transfers. Generally the higher the pressure redistribution properties the harder bed mobility is. A foam mattress may not provide the same level of immersion and envelopment or offloading, however because it is a more static, solid option it also has less impact on independent movement. With an alternating mattress there is usually a “hard” or “transfer” mode but pressure risk will be increased if this isn’t returned to normal cycle for lying.

Like wise with the ROHO mattresses, transfers need to be considered. The mattress is available in sections and can be inserted into foam surrounds to assist with bed mobility and transfers.  


Bathroom and Personal Care Tasks

Independent self-care and ADLs can take longer for those with impairments and may be completed from surfaces we don’t consider. When assessing for pressure risk it is important to consider all the support surfaces that are being used.

Commodes come standard with a seat made of similar materials to a toilet seat. Although this is not an issue for someone with full sensation, the ability to move and for short periods of time, it is important to find out more about the tasks and time spent to ensure it is not a concerning risk factor. If risk is identified, consideration of the seat needs to be addressed with padding or a pressure redistribution surface. 

A ROHO Toilet Seat Cushion

Skin tears and injuries do not always come as a direct result of pressure forces, but they can become chronic wounds. Not having the strength to complete a side transfer or mis-judgement may result in the user landing on a surface not intended eg the wheelchair wheel, and sustain a skin injury. Transfer style and other assistive technology such as slide boards may need to be addressed to prevent injury.

Be aware of all surfaces! Be open and have discussions around PI risk, prevention strategies and equipment options. Pressure injuries are for the most part preventable. Chronic wounds can have significant negative impacts both physically and emotionally. Our education team can provide clinical support and education around pressure care and the clinical application to our equipment ranges.

You can contact us at education.au@permobil.com or reach out to your local Permobil Territory Sales Manager.  


 

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.

This week is Wound Awareness week in Australia. Why is it important to be aware of wounds? Chronic wounds affect half a million Australians with an annual estimated cost of over 3 Billion dollars (Wound Aware website). The definition of a chronic wound encompasses any wound that is resistant to healing.

While Pressure Injuries (PIs) have a direct correlational-causation with peak pressure and shearing forces, the causation of a chronic wound may not be pressure related, however pressure injuries are  the most common causation of a chronic wound.

The impacts on those who experience chronic wounds can extend beyond the physical issues of the wound to affect quality of life and general well-being. It is essential that we consider equipment and best practice guidelines when working with people to assess and trial Assistive Technology options. For more information about wounds and ways to create awareness check out some of the resources at the official website here.

To acknowledge and promote the importance of wound awareness, this week’s blog is a reminder on some of the considerations when prescribing pressure redistribution surfaces for beds and wheelchairs.


Creating Awareness

A historical approach to education around PIs has often included graphic images to shock us into the serious consequences that can result. Although the serious nature of chronic wounds cannot be underestimated, it is important to understand the development of PIs.

Education should be around prevention and monitoring. Yes, an early stage PI usually presents itself as a red mark on the skin surface, but not all red marks on the skin develop into PIs. When prescribing new seating we need to not just tell someone to monitor for red marks, but also advise them on what to do if they get skin markings and what kind of information you may want. As a clinician, the first questions I want to know are the location, if the skin blanches and how long it takes for any red marks to appear and fade.

It is more important that a user is empowered to understand the risks of PI and understand how to decrease those risks. It should become second nature to routinely monitor skin integrity and to know who to contact and when. Open discussions and general awareness can help in breaking the stigma and embarrassment that prevents some people from seeking early intervention.

Post-discharge from your services, who should they contact if they have PI concerns? For those not involved with regular services, you may advise them to re-contact you or their GP.


Who is at risk of a PI?

When prescribing AT, we need to consider the risk factors for the individual. A good risk assessment will not predict who will sustain a pressure injury but can assist in identification of factors that can be addressed to reduce risk. Those at risk include:

  • Individuals who are unable to independently adjust their posture or position
  • Individuals who present with asymmetrical postures and or uneven tonal patterns
  • Individuals who constantly “slide into PPT” (Posterior Pelvic Tilt)
  • Individuals who have history of PIs – old scar tissue
  • Individuals who are sitting or lying for prolonged periods
  • Ageing population

Where do pressure injuries occur?

PIs related to sitting or lying occur around bony prominences, often where the layer of tissue between the bone and skin is minimal such as the sacrum when sitting in posterior pelvic tilt.

Positioning will contribute to the area at higher risk, so the list above indicates the most common areas for sitting and lying supine. When lying on the side however, the greater trochanter and ear are also vulnerable areas.


Seating considerations

During the clinical reasoning process, it is important to consider both the postural positioning and skin protection requirements of each individual. This should guide the identification of the type of seating requirements. The design and materials of the proposed seating options will differ depending on goals and what approach you are taking to pressure redistribution and positioning.

Are you trying to reduce an abnormal postural position or accommodate to increase area of loading? If so, you will need to consider the adjustability and modularity of the seating to achieve the required points of control and contours.

Are you wanting to offload the ITs by increasing the loading of the Greater Trochanters? Consider the types of foam used, the contour and the depth between the areas of the trochanter ledge and the Ischial well.

Are you trying to provide maximum pressure care for someone that doesn’t have complex postural issues but has a history of PI? The Dry Floatation Technology design of a ROHO High profile cushion offers maximum immersion and envelopment and allows individualised set up.

 

Or are you trying to find a cushion for intermittent use such as community outings or the user is at low risk of a pressure injury and has no postural issues? There are a range of basic foam cushions available on the market.

If you would like more information on potential seating solutions or want further clinical support you can contact the clinical education team education.au@permobil.com. If you want to know more about seating and positioning this week’s live webinar on 20 August focuses on Pelvic Obliquity. To Register

 

 

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.

 

 

Posterior Pelvic Tilt    


Last weeks live webinar looked at the very common posture that comes from a posteriorly tilted pelvis. Whilst we often discuss the pelvis as the foundation, it is important to appreciate that to support the pelvis back to a neutral position, the primary point of control comes from the backrest. Yes the cushion features will certainly assist as will a pelvic support belt, however we can’t overlook the crucial role the backrest plays. Today’s blog will take a closer look at pelvic blocks as a point of control for reducible posterior pelvic tilt (PPT)  


Pelvic Block

A pelvic block refers to the provision of an insert or contouring in the back support to adjust the force at the pelvis.  Providing an increased force at the posterior aspect of the pelvis can assist in both reducing a PPT and maintaining a neutral pelvis.

There are various ways we can create this force, lets take a closer look at some of the potential options. 

 


Tension Adjustable Backrests

 

 

If clinical reasoning identifies an upholstery back rest, I will always consider a tension adjustable option first. A tension adjustable backrest uses horizontal straps under the front upholstery. By adjusting these straps you can increase or decrease the force as required. Next time you have an opportunity I recommend you try it out. First sit in the wheelchair without adjusting it so you can feel the difference. Next loosen off ALL the straps. Now tighten the lower straps of the backrest from the seat base to the Posterior Superior Iliac Spine (PSIS)as much as you can. Now gently work your way up the straps doing each one above the tightened straps to follow the contours of the trunk position wanted. By having the lower straps tightened you will feel a more upright trunk posture coming from the increased force at the pelvis.

 

 

Another Back rest that uses a similar concept to a tension adjustability, is the Acta Relief. This is a unique backrest. Equipped with an oversized aluminum shell cut-out to allow deeper immersion into the back. It has adjustable Boa system that can be tightened and loosed off at different areas. Whilst a similar concept to tension adjustable straps, the Acta back can provide stronger points of control that maintain and do not slip as webbing straps can, but it has to be removed if chair is regularly folded.


Aftermarket Off The Shelf Back Supports

Most after market or ridged backrests consist of a shell and foam interface. Mounting brackets may provide adjustment for active seat depth and STB angle. You need to understand what you are trying to achieve before identifying appropriate equipment. There may be a standard adjustment such as a dual or hinged shell which enables the shell to be opened at a hinge joint usually just above the PSIS.

Some aftermarket back rests are supplied with dense foam wedges that can be placed between the shell and the foam interface, image 6  shows inserts provided with the  Dreamline contour back rest.

 


Adjustable Backrests

There are several adjustable backrests on the market that allow you to adjust the contouring of the support surface to create individualised support. These tend to work well with significant complex and asymmetrical postures, and for those with ongoing changing postural needs such as those with aggressive progressive conditions. I am frequently surprised when I see clients with these types of backrest with NO adjustment to the contour…it is as flat as the day it was packed at the manufacturers. Whilst we could consider these types of backrests for ongoing needs, they still need to be appropriately selected and individualised to the users current needs. I have had significant success in even minor adjustments through the trunk contour when the point of control has been set up appropriately and is proving the support required. Materials of the backrest are crucial when working with these adjustable backrests. Think critically with the clinical reasoning process, how much force do you want compared to how much immersion. What are you trying to achieve? With  a back support, it is essential to simulate the map findings and identify the impact of gravity and how you can achieve the required support for the end user. An adjustable back is easy to create a pelvic block in as you can adjust the contours to meet the users needs by taking out or adding in foam pieces. When you apply good contouring that provides the appropriate level of support you can create an appropriate solution for the user. 

 

These BAC pads made of a dense closed cell foam and are designed to be moved and overlapped so you can easily build up a pelvic block and other contouring as it is required. Pictured are the standard BAC. 


Making a Pelvic Block  

Not sure if a pelvic block would make a difference with a clients existing seating? Consider doing the towel trial.  Taking a small washcloth or hand towel fold it into several layers and place it at the pelvis area where you want support (seat surface to PSIS height), what I like about this method which I first saw over 15 years ago when Bengt Engstrom facilitated a workshop, was the ease in which to get further information. Most households will have a small towel to fold up and use. I could change the thickness and height to see the impact it could have just as I could place it in front of or behind the foam interface depending on the materials of the backrest.  Bengt is a Swedish Physiotherapist, author and original designer of our Corpus Seating System in the Permobil power bases.  I will use the towel as part of the assessment process, however it can be trialled if wanting to trial different thicknesses etc. I have made multiple pelvic blocks. I find an electric bread knife is a cost effective tool for these kinds of projects so keep one in my tool kit for these purposes.

Step 1 – Take a piece of foam in required density, it should be the thickness you are wanting, I often use a dense 1 or 2 inch.

 

Step 2 - cut a rectangle, approximately as wide as inner back rest (A)and height of seated surface to PSIS (B)

Step 3 - Chamfer off the top corner edge to create transition from pelvis to back support with knife

Step 4 - Attach between the shell and foam interface 

 

A individualised custom pelvic block to provide the force for a reducible posterior tilt…..now don’t forget the cushion and supports to complete the solution! If you have questions about any of the concepts or products featured please contact us at Education.Au@permobil.com

 


 

 

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.

 

Reducing Barriers to ROHO Cushion

Set Up    


 

  


ROHO have been manufacturing pressure redistribution surfaces to assist wheelchair users and those at high risk of pressure injury for the past 49 years. This week’s blog looks at how and when the SmartCheck may be used to assist in cushion set up and ongoing use.  


SETTING UP A ROHO CUSHION

Historically, initial set up of a ROHO air cushion involves over-inflating the cushion and then releasing air in relation to the individual user. As air is released, the user is immersed and enveloped leaving a layer of air between the user and the seat interface. Palpation of the lowest bony prominence (in most cases the ITs or Sacrum) is part of the process in guiding both the seated posture and the optimal air levels.

Research and EBP has repeatedly shown that a well-set up air cushion provides a high level of pressure redistribution and many facilities and services will provide an interim ROHO cushion when a pressure injury or high risk of injury has been identified. The main barriers to this type of cushion meeting a user’s needs is in establishing correct air inflation levels.


TOO MUCH AIR

When an air cushion is over-inflated we are not able to immerse in it effectively. Many users that find an air cushion unstable are actually sitting on an over-inflated cushion, rather than immersing into it as designed. When over-inflated, there is also increased peak pressure at the lowest bony points. Let’s think about a tyre, a tyre is filled with air. They are usually highly inflated and the more air that goes in the ‘harder’ they become.

The material of the cushion that contains the air will also impact the immersion and envelopment capacity of the cushion. Which is why ROHO is very particular about what their cushions are made of, hence why they make all their neoprene on-site.

NOT ENOUGH AIR

When a cushion is under-inflated and there is no layer of air between the user and the seat base, there is a risk of bottoming out and increased pressure. The cushion is designed to have a layer of air under the user, however we find that air cushions incorrectly set up are more likely to have too much air rather than too little.


WHEN THE SET UP GOES WRONG

I like to set up an air cushion with a user consciously. What I mean by that is I tend to talk through the process before and during the set up. I want them to be aware of the changes in how they are sitting as the air is released. If there is a wall mirror in the room we will often do the set up in front of it and talk about how they are immersing (or sinking) into it as the air is adjusted.

Many long term ROHO users know straight away if their cushion is correctly inflated by how they sit and feel. Others may need more consistent monitoring of the inflation level and assistance in checking and setting up. The set up and maintenance of inflation has been a barrier in some settings. Initial set up is often completed by a therapist but the user may need to adjust the inflation levels over time. I had one client who reported that her carer always added more air to the cushion even though she knew it required less.

Sometimes therapists arrange hire of an air cushion and it is sent directly to the end user. I once went to visit a client who was hospitalised for a pressure injury. The custom cushion had been removed and she was sitting on a ROHO. It was so over-inflated it was difficult to press down on the fully expanded cells, when I queried who had set it up for her she advised it was a maintenance worker.

So how do we overcome or reduce some of these barriers? For some, it is about education and training but others may need a more concrete cue. How can someone who has experienced a pressure injury and is anxious about their cushion set up feel more confident that it’s configured to meet their needs? For those that don’t know about the SmartCheck, it is a tool that can assist in checking the inflation level of a ROHO Single Compartment Cushion.

ROHO SMARTCHECK 

At a simplistic level, the Smart Check uses sensors to guide the appropriate level of inflation for the user. The SmartCheck is separate to the cushion and attaches as required to any Sensor-ready cushion. All single valve, single compartment ROHO cushions sold in New Zealand and Australia are Sensor Ready. This enables a SmartCheck device to be added at any stage even if not identified as a need until after someone has purchased the cushion. 

Once attached to the cushion, the SmartCheck uses illumination and arrows to enable you to set up and check the inflation level. 

SmartCheck is easy to use and can provide peace of mind to those at risk of pressure injuries and to those supporting them. It is a good idea to learn how to set up, override and reset to factory default settings. We have a great set up guide which is available HERE that walks you through the steps. 

If you want more information on the set up and use of SmartCheck, you can reach out to your local Territory Sales Mannager or contact us at education.au@permobil.com

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.

Smart Actuators – What are they and what do they do?   


Actuators are used on power wheelchairs to make the seat move – so it is an actuator that makes a seat move back into tilt, or the back support recline, or the leg supports elevate.  A smart actuator is an actuator that has a sensor attached to it, allowing it to sense its position in space.  A smart actuator is able to sense its position at any point between being fully retracted or fully extended, or for example whether the seat is in no tilt, or in 15 degrees of tilt, or 45 degrees, as opposed to being in no tilt, or full tilt.  These sensors are also linked to the specific actuator, so use of another actuator will not interfere with the information it provides, for example the use of power recline will not interfere with the tilt actuator knowing how much tilt it is in.

Why are smart actuators useful?  Smart actuators allow for very specific programming of power seat functions, taking the guess work out of using these functions and making them easier for the end user to manage.   For some users, smart actuators can be the difference between successfully managing the power functions on their chair (and hence maximising their independence) and the chair being too complex, and an alternative solution being required.

Smart actuators allow for limits to be placed on how a power seat function moves, so a tilt or recline actuator can be limited on how far it will allow the seat to move back, or the leg supports limited as to how high they can elevate.  Restricting how a power seat function moves can be helpful when a person requires a power seat function for a particular purpose, however there are risks associated with this function if they use it outside a particular range.  For example a person may require the use of power recline to assist with pressure relief, however too much recline can create issues with reflux after meals. 

The Corpus VS power articulating leg supports are another example of when restricting actuator movement is useful.  These leg supports offer 8” of vertical travel, meaning they can be programmed to lower the footplate to the floor for ease of transfers.  Without the smart actuator, a person needs to be able to judge when the footplate has reached the floor, if they don’t lower the footplate far enough, their safety may be compromised with having a small lip to manage, or if they lower the footplate too low, trying to push it through the floor, there is risk to damage to the actuator with potential risk of early failure.  The smart actuator allows the leg support actuator to be programmed to stop when the footplate reaches the floor, promoting a safe transfer and preventing damage to the actuator.

On the Permobil chairs, the smart actuators allow for programming of both memory seat functions and Independent Positioning Mode through the Intelligent Control System (ICS).  Both programming functions allow for a user to access a particular seated position through the use of one switch or button, even though the position may require use of multiple power functions to achieve.

Independent Repositioning Mode, or IRM, is use of specific power seat functions programmed to move in a sequential order, with each seat function moving to the desired angle before the next function starts to move.  IRM utilises power tilt, power elevating leg supports and power recline sequentially, with varying angles able to be programmed depending on the users needs.  This feature is typically used for those who have high pressure relief needs where it is vital that power tilt is used before power recline to maintain the persons posture in the seat.  Use of IRM means that a user does not need to remember which sequence to use the power functions in, where they are taken through the required sequence with use of a single switch or button. 

Memory seating is similar in that multiple power seat functions are involved, however slightly different in that the actuators move simultaneously, the idea being to move a person into their desired position as quickly as possible.  Memory seating has more varied uses, from setting of a ‘home’ position which can be the users preferred sitting position, to positioning for transfers and function.  For some users they have a particular position that allows them to transfer in/out of their chair independently, or a position that allows them maximum function at a work station, these are positions that can be programmed into the chair, allowing the user to move in and out of these multiple times per day with ease. 

For more information on Independent Repositioning Mode or Memory Seating, on our Permobil chairs, please contact sales.nz@permobil.com  


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.