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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.

 

 

Funding Considerations for Power Standing  


Power wheelchairs that offer the option of power standing have several physiological and functional benefits, however accessing funding for these chairs can be challenging.  Funders are keen to fund the most cost-effective option, in many instances this is provision of a separate power wheelchair and standing frame.

Having two separate solutions may work well for some, particularly for those who are unable to manage the complexities of a power stand up chair or those who have a well-established routine in place with a standing frame.  However, for others having a two separate solutions may not be ideal, in this blog I am going to focus on two common examples.

For many teenagers or young adults, regular use of a standing frame can become challenging due to a variety of reasons – it may no longer fit well into the school routine, transfers in/out of the standing frame may be challenging, or the limited mobility while in the standing frame, and often time away from their peers, creates issues with compliance.  This can result in limited opportunities for standing and weight bearing at a time when they are moving through puberty and a rapid period of growth.  

For some of these young adults, there is potential to demonstrate how provision of a power stand up chair can be cost effective, often through demonstrating the potential to reduce carer support hours and with functional gains leading to increased independence.  If a young adult has, or may soon need, carer support hours to assist with transferring in/out of their standing frame, these are hours that are no longer needed with a power stand up chair.  A young adult also has the potential to increase their independence with access to power standing, particularly if they have reasonable hand function.  Provision of a power stand up chair may mean that a teenager or young adult can come home from school independently, being able to access their home and food from the pantry or fridge and have independence at home without needing their parents or a carer.  Some teenagers or young adults, particularly males, may also be able to use the toilet independently with use of power standing, further increasing their ability to be at home or school without support.  A power wheelchair with power standing often results in increased function, or reduced need for support, at school, typically in science and technology subjects.  Science and technology are subjects that are typically undertaken at raised tables or in an environment where a person is standing, making access to these subjects from a wheelchair more challenging.  Use of power standing can reduce the need for environmental modifications and a person may be able to participate in these subjects alongside their peers.

Another group of wheelchair users where access to power standing can often be easily justified are those with conditions that create increased tone in their lower limbs, limiting their ability to stand and walk.  For this group, regular standing or weight bearing often assists with managing their increased tone, prolonging their ability to stand transfer.  For many their ability to stand independently declines over time, and a standing frame may be considered, however independent transfers in/out of the standing frame may also be an issue.  For these people access to power standing can result in a reduction in the number of carer support hours required – in the short term as assistance is not required to manage a standing frame, and potentially in the medium term as independent transfers are maintained for longer.  Further cost benefits may occur if use of power standing maintains a person’s independence with activities of daily living at home and/or reduces the need for modifications to their environment. 

When completing funding requests for a power wheelchair with power standing, a person’s goals is often the best place to start – particularly those that are likely to maintain or increase their independence.  These goals can be complemented with information on their carer support package – and how this may change if the goals are achieved.  For those who were previously had some mobility on their feet, provision of power standing may allow a person to remain living at home independently or with minimal support, while for some teenagers and young adults, there can be a significant reduction in carer support hours, or reduced reliance on family, with provision of power standing due to an increase in functional abilities and the resulting independence it gives them.  This ability to maintain a current support package, or potentially reduce the number of carer support hours required, can be an objective way of demonstrating to the funders that a power wheelchair with power standing is a cost-effective option.

For more information on power standing on our Permobil chairs, please contact Sales.NZ@permobil.com

If you are wanting to know more about prescribing power standing, please join us on Thursday 23rd July at 1.30pm for our free webinar.  

To Register   


 

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.

 

ActiveReach – Increasing Vertical AND Horizontal Reach 


Last week we discussed the potential benefits of ActiveHeight, a feature that can increase functional independence for many, however for some, horizontal reach continues to be an issue.  Horizontal reach can be challenging for those with limited trunk control, it may be a person has difficulty reaching forward from their wheelchair seat, or they have limited rotation for when they need to access a surface side on.  Some of these users continue to have reasonable hand function and could increase their functional independence if they have a means of reaching forward to allow functional use of their hands – which brings us to ActiveReach.

ActiveReach incorporates the use of anterior tilt to bring a person up and forward, this can be further complemented by additional power functions to optimise positioning, depending on the amount of ActiveReach required.  ActiveReach allows a person to increase their functional reach by 3” for every 10 degrees of ActiveReach used, with a maximum of 45 degrees of ActiveReach available on the F5. 

The use of the modified Functional Reach Test can be a means of assessing whether a person may benefit from, or the functional reach gained from, using ActiveReach.  Use of the modified Functional Reach Test can complement functional goals identified by the person, for example a person may identify that they are having difficulty preparing a meal on the stove top as they have difficulty reaching forward to safely stir the food in the pot, or to use utensils to serve the food they have prepared.  The modified Functional Reach Test can be used to confirm that the person has limited functional reach, and to show that their functional reach has increased during a trial.

ActiveReach and Active Height can also be used together to allow a person to reach into overhead cupboards, with ActiveReach further increasing a person’s vertical height, as the anterior tilt component of ActiveReach will lift the rear of the seat providing additional height.  This combination of functions can be useful for those who have limited shoulder range of movement and are needing additional height to access unmodified environments, for example reaching items on a shelf at the supermarket.

ActiveReach can also be used to assist with standing transfers.  Some users have difficulty initiating a sit to stand, particularly if they are unable to move forward on their seat to allow their feet to be placed slightly behind their knees.  Use of ActiveReach can place a person in a position that allows for ease of moving from sitting to standing, potentially maintaining an independent or assisted stand transfer.  Maintaining this transfer can be important for those who are active in the community or wish to minimise their carer support requirements.

Maintaining independent transfers is further promoted by use of the powered foot support, this foot support is the same one used on the F5VS (Power standing) that allows for a change in vertical height in the footplate, potentially allowing a footplate to be lowered to the floor to allow for ease of standing transfers.

The combination of power seat functions used in ActiveReach is complex, however use of ActiveReach can be made easy for the end user by using smart actuators.  The smart actuators on the Permobil chairs allows for the desired ActiveReach position to be programmed into the chair, allowing a person to move to this position by use of a button or switch.  This means that the user does not need to remember what sequence to use the power functions in, or where each function needs to be positioned to, for successful use of ActiveReach.

For more information on ActiveReach on our Permobil chairs, please contact sales.nz@permobil.com  Our Customer Service team will direct your enquiry to the relevant Territory Sales Manager for your region.

If you are wanting to know more about prescribing ActiveReach, please join us on Thursday 23rd July at 1.30pm for our free webinar.  

To Register 


 

 

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.

 

 

 

 

Power Seat Elevation - Desirable or Essential?


This week the spotlight is on power seat elevation, also known as power elevating seat or hi-low.  Power seat elevation is a powered seat function that raises and lowers the seat, to provide a varying amount of vertical seat to floor height. It does not change the seated angles of the seat relative to the ground.

 

Power seat elevate is a power wheelchair seat function that can increase the quality of life for an end user, however it is often a seating function that funders consider ‘desirable’ as opposed to ‘essential’.

For many of our users, we can justify to the funder how power seat elevation is essential to maximise an end user’s independence, often to facilitate independent transfers or increase a person’s vertical reach.  Power seat elevation allows the user to adjust the height of their seat to optimise transfers, either by raising the seat to floor height to allow for ease of standing transfer, or to allow the seat to floor height of the power wheelchair to be set just higher than the surface they are transferring to, for ease of use of a transfer board.

Power seat elevation also allows a person to increase their seat to floor height to increase their vertical reach, allowing them to reach items such as a light switch or items in a cupboard that may otherwise be beyond their reach.

RESNA (Rehabilitation Engineering and Assistive Technology Society of North America) have recently updated their Position Paper on the Application of Seat Elevation Devices for Wheelchair Users.  For those new to the RESNA Position Papers, these papers summarise current research and best practice trends for a variety of topics.  The 2019 update on the use of power seat elevate provides additional insight on where power seat elevate may be beneficial, or perhaps even essential, for end users.

A person is typically prescribed a power wheelchair as they do not have sufficient upper limb function or endurance to achieve all day independent mobility in a manual wheelchair, hence are more likely to have issues with upper limb function and/or fatigue. 

A person seated in a power wheelchair is typically positioned at a lower level than their standing peers, which forces a wheelchair user to maintain an upward gaze to achieve eye contact.  This can result in a person sitting in increased cervical extension for prolonged periods of time, this posture can be uncomfortable for any person, and can ultimately lead to pain.  For those who have an increased thoracic kyphosis, their posture may result in them sitting in a degree of cervical extensional already, hence they may not have sufficient range of movement to allow them to make eye contact with a person in standing.

Use of power tilt can assist with improving eye contact for some users, however this may not be ideal for others who have good upper limb function and need to be positioned upright to maximise their independence.

Many wheelchair users are also living and working in environments that are designed for a person who is standing and walking, for example kitchen bench and cupboard heights are typically set for a person in standing, as are light switches and elevator buttons.

A wheelchair user may have sufficient range of movement to access these environments, however this often results in them reaching above their head, hence using their shoulders towards their end range of movement frequently throughout a day, which can also result in pain and fatigue.

When considering whether to request power seat elevation on a chair, we perhaps need to consider the frequency and duration that a person needs to undertake overhead activities and the potential impact of this over a length of time.  It may be that transitioning a person to power mobility may resolve any shoulder pain that was caused by self-propelling, however a person may still experience pain if they are needing to reach overhead a number of times each day as part of maintaining their independence at home or work.

So how much seat elevation can we get on a chair?  The amount of seat elevation available varies between 8 and 14 inches, and how this is achieved varies from chair to chair.  Power seat elevation on the Permobil chairs is referred to as ActiveHeight, this allows 12” of seat elevate on the Permobil F3 and M3 and 14” on the F5 and M5.

In addition to elevate, the seat also moves back over the base by 3.5” to allow maximum stability while driving the chair in an elevated position. This stability is important for users who may be using ActiveHeight outdoors or for extended periods during the day.

For more information on ActiveHeight on our Permobil chairs, please contact us at sales.nz@permobil.com or call 0800 115 222.

If you are new to prescribing power seat functions or want to know more, please join us on our webinar this Thursday 9th July at 1.30pm.

For further information on the RESNA position papers, follow the link here 


  

 

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.

 

 

 

Where is the Drive Wheel and Why Does it Matter? 


The drive wheel on a power wheelchair is the larger wheel if you are looking at your wheelchair or client’s wheelchair. The location of this drive wheel can have a large impact on how the power wheelchair drives and manoeuvres in different environments.

There are three main types of drive wheel configurations on power wheelchairs: front-wheel drive, mid-wheel drive, and rear-wheel drive. In this blog, we will focus on front-wheel drive.

Front-Wheel Drive

The front-wheel drive power wheelchair is typically going to be good for manoeuvrability indoors and optimal for outdoor use. This is because of the larger drive wheel being the first wheel to overcome the uneven terrain versus the smaller casters. Because the front wheels are connected to the drive motors, these pull the casters over obstacles and through various terrains versus if the casters were the front wheel. In the case of the casters being in front, the casters are being pushed, the force generated is forward and downward. This would be similar to a ploughing effect and can increase the likelihood of becoming stuck in certain situations. For individuals looking to go over all terrains, the front-wheel drive wheelchair may offer the best solution.
Another benefit of front-wheel drive is the smoothness of the ride. Look at how many wheels are on the ground. In the case of front-wheel drive there are four wheels versus the six wheels with a mid-wheel drive chair. This means that as the end-user goes over a bump in a front-wheel drive chair, they would feel the force of that bump two times versus three in a mid-wheel drive. This can also be important for individuals that may easily lose their positioning when going over any uneven terrain.
We could talk about front-wheel for hours, but the final benefit to mention is the front-wheel drive chair’s smallest front turning aspect. In all the configuration options, the chair will turn on its drive wheel.

The photo below shows an example of a bathroom. In this bathroom the sink is positioned against the wall. Because the wheelchair turns on its drive wheel and the end-user can only pull themselves so close to the wall before turning, we can see the only chair to gain full access to the sink is the front-wheel drive. Does this mean that everyone should have a front-wheel drive wheelchair? No, but it does mean that it is important for clinicians, suppliers, and clients (end-users) to consider the environment that the client lives in. 


Often, I hear that people stay clear of front-wheel drive because it doesn’t have as small of a turning radius as mid-wheel drive and it is harder to learn to drive. Both of those statements are true. The front-wheel drive will have a slightly larger 360 degree turning radius, but as you saw above it has the smaller front turning aspect which may be utilised more than someone turning in a full circle. Front-wheel drive may be less intuitive to learn how to drive versus mid-wheel drive, but with a little practice and a few key tips, many users find front-wheel drive to be just as easy to learn as mid-wheel.

The two key points I like to teach someone when learning to drive a front-wheel drive wheelchair is:

  • Hug the corner. When going through a doorway the end-user will want to “hug” the corner or keep a tight turn.
  • Turn towards the problem. For example, when positioned adjacent to a wall/barrier, turn toward the wall/barrier, then slightly reverse to allow the rear casters clearance for turning in the desired direction. This might sound complicated, but if you remember to turn into the problem you will easily manoeuvre away from the problem.

Keep in mind that not everyone will benefit from the same drive wheel configuration and it is important to ask the questions and complete an evaluation to determine which drive wheel would be best for you or your client.

Interested in learning more about drive wheel configuration? Join our Clinical Education Specialist, Rachel Maher this Thursday June 25th at 2.00pm for our free webinar.

 To Register

Rachel Fabiniak

Director of Clinical Education

 

 

Seating Assessment Form


As part of our recent seating assessment webinar series, we were excited to release our seating assessment form for prescribing therapists as both electronic fillable and print versions. This assessment form was developed in response to multiple requests from therapists and service providers.

Due to the wide variety of our end user seating needs, we have tried to make it as holistic as possible. As such, therapists working with more complex needs may need to add additional information and those working with less complex needs may opt to use only certain portions.

Likewise, if you are working with specific populations you may want to add some more specific questions into your assessment process. If you missed our seating assessment series repeats and would like to view those webinars, don’t fret! Just send us an email to express interest for a repeat of this series again at education.au@permobil.com.


Prior to a Seating Assessment

A well-structured and completed seating assessment along with a MAT evaluation can lead to better and more timely outcomes for end users. Being prepared before you book a seating assessment can assist you with the process from start to finish. What is the referral for? Does the end user meet the eligibility criteria for the local funding source? As a prescribing therapist, would this referral be within your scope of practice? Do you have the skills to take it on? If not, have you identified appropriate supervision and mentoring to support the process?

These are some of the initial questions we need to be asking when a client is referred to us. This may require further communication with the referrer or with the end user. Add as much information from the referral into the form before you go to the trial and be sure to confirm with the user if it’s correct. This will assist in you being more conscious of the clients’ needs and the types of questions you can ask to ensure you are getting the appropriate information.


Historical knowledge and the Interview

As with any assessment we need to be documenting the information we gather and remember that it contains sensitive and private data. Systematic documentation within an assessment not only assists with the clinical reasoning process but is also crucial information when it comes to writing the justification and articulating your clinical reasoning.

With the vast amount of information we use in the clinical reasoning process, an assessment form can assist in gathering the information you need when you come to identifying potential trial options and writing the funding justification. You don’t always have to ask the same questions or all of the questions. An assessment form can also cue you about additional information that could be important and relevant to the clinical reasoning process.


The Seating Assessment

Our seating assessment form uses the ICF model criteria to enable a holistic overview of the users needs. It is important to gain rapport and trust as an assessor and to work with the end user and their supports to get best outcomes. What is the user’s mobility goals? Postural Goals? Functional goals? What can they achieve with current equipment, what can they not do now that they want to be able to do in their next chair?

Documentation including measurements of current seating setup and mobility base can also assist in both the funding application and in identification of potential trial option configurations.


MAT Assessment

The Mechanical Assessment Tool is a crucial part of the seating assessment process as it identifies the capacity of positioning based on bio-mechanical and physiological principles. For more information on the MAT you can check out our previous blog on MAT assessment or contact us at Education.au@permobil.com especially if you’re interested in our ongoing MAT training opportunities.


Bringing it all together

Your seating and mobility assessment should guide you through the process and collect information that leads you to potential product parameters for your clients. Once identified, these parameters can be used to identify potential trial options. Sometimes we can rule out certain products based on the assessment and needs but the only way we can ensure a solution will meet a user’s needs is to complete a trial.

Ideally, a trial should always be completed within the environment of intended use. Make the most of the trial opportunities. If you are adding a specific feature to a chair because you think the user would benefit from it, then include the task in the trial and document how the task is now achievable.


When you attend the trial remember to review the assessment info before you go or better yet, have it with you so you can check that the configuration matches what you identified and document any crucial changes based on the trial. With these tips in mind, a seating assessment can be both thorough and practical!

Our education team is always available to discuss clinical matters and potential options to support you through the process, so don’t hesitate to reach out!


Tracee-Lee Maginnity
Clinical Education Specialist

Weight or Configuration: Which one is more important for a manual wheelchair?


When discussing manual wheelchairs, we often focus on the idea of having the lightest weight wheelchair possible. Yes, weight can be an important factor when we think about propelling a manual wheelchair all day. We also have to consider where the weight in the system is coming from. I said system here because it is not just the frame of the wheelchair that we should focus on when discussing weight. We also need to consider the weight of the components such as the wheels, backrest, cushion, etc… and the weight of the user!

Studies show that the average full-time manual wheelchair user completes 2,000 to 3,000 pushes every day! This is an enormous amount of work that we are asking the shoulders to complete. The less weight on the chair, the less demand we place on the shoulders, right? This is true, but if we don’t have the proper configuration, then even the lightest weight wheelchair will be difficult to push. Therefore, weight is important, but what is even more important is the configuration. The configuration of the chair and how the person is configured to the wheelchair can be more impactful than just getting the lightest weight manual wheelchair.

Let’s think about those big hospital wheelchairs and how hard they are to push. This is because of the weight to an extent, but it is also because they are not properly fitted to us. They are meant to be a one-size fits all. What happens when we think about wheelchairs as one size fits all? Have you ever just sat in a wheelchair that is not fitted to you and propelled? Most of us in the industry have, but how many pushes did we complete? 10? 20? Did we propel on a smooth, flat, indoor surface? Then we maybe got up out of this poorly fitted wheelchair after 20 pushes on a flat surface and we think “well that wasn’t too hard”. Now, let’s take a step back and think about our client. Is our client only pushing 20 pushes a day? Are they always on level surfaces? Do they have fully innervated and strong shoulders like you do? How about their posture in the wheelchair and how it affects the position and movement of their shoulder? What about pain? Are they only propelling a few times a year or are they planning to propel every day for the next 20 years? It can be easy for someone to trial a poorly fitted wheelchair in a perfect environment, but we have to consider the individual, their environment, and their long-term goals. 

For an individual’s wheelchair it is important that we throw out the idea of one-size fits most and we instead think of the phrase: “fit the wheelchair like a prosthetic”. Let’s think about this idea – Fitting the wheelchair like a prosthetic. What do I mean? We can think about the individuals with amputations that have a prosthetic and how important that perfect fit is. The fit of that prosthetic is crucial in the success of the individual’s mobility. If the fit is not correct, they often will have pain, skin issues, and eventually may not be able to use the prosthetic for mobility. They may be forced to be in bed or sit in that recliner in the corner because of these challenges with a poorly fitted prosthetic. The same holds true for a manual wheelchair user. The manual wheelchair should be an extension of the individual using it and if we truly want the individual to have the easiest time propelling and help to limit the risk of shoulder injury – the wheelchair should be fully customised to the individual. It should be fitted just in the same way that a prosthetic is fitted to an individual. This means that we can’t always just have a wheelchair that is out of a box and then custom configured to add the components that we need, but instead the wheelchair should be custom built to the individual.

If you're interested in hearing more about achieving this custom fit join our LIVE webinar on June 11th at 2.00pm  on TiFit: How to achieve a tailored fit for every individual to learn more.  

To Register

Common Concerns About Early Power Mobility Devices

Part 12 - The last part in our series about developmental milestones in early childhood focusing on mobility.  


Perhaps one of the mostly widely known authors on this topic are Wiart and Darrah from an article published in 2002 entitled “Changing philosophical perspectives on the management of children with physical disabilities: Their effect on the use of powered mobility.” The authors highlight the paradigm shift that occurred around that time frame and that several factors contributed to the new philosophy.

Two very important political changes occurred

1. Change the language

In 2001 the World Health Organization (WHO) changed the language associated with people with illnesses or conditions. Before this, terms such as handicapped, disabled, or abnormal were used to describe people. This language attributed the physical condition as something “wrong with the person”. Additionally, passing of the Americans with Disabilities Act (ADA) in 1990 contributed to the conversation of how to characterize disabilities. The ADA admitted that the concern was with the environment. If ramps were used instead of stairs the person using a wheelchair could “participate” in activities of their choice.

2. Providing access 

In conjunction, the new WHO model; the International Classification of Functioning, Disability and Health (ICF) describes functioning using two components

  1. Body structure and function, and
  2. Activities and participation

Taken together they ascribe that a person may have a disability but it is the lack of access (stairs in this example) that “handicap” the person. Therefore, changing the environment allows access to the environment. 

So, what does this have to do with wheelchairs? According to the ICF a wheelchair is part of the environment. The reason infants and young children have difficulty with environmental exploration is because there has not been a suitable wheeled mobility device for many young children with disabilities until the Explorer Mini by Permobil was developed.  


The Importance of Perception 

Caregivers, and clinicians have been reluctant to recommend or accept a wheelchair as it may be seen as a “last resort”, a failure, a sign of a disability (2). In fact, the disability is not having access to one’s environment! This is particularly troubling for infants who need environmental exploration to learn, play, socialize and find who they are in their world. Not having access to a properly fitted mobility device is the handicap. 

Six mothers participated in an in-depth interview regarding the use of power mobility (2). In this study, all mothers stated that their child demonstrated increased independence and personal control. Further stating that the increase in independence enabled their children to engage in meaningful life experiences (2). Finally, the mothers in this study also noted that peers and strangers reacted positively to the child, seeing the child rather than a device and realizing that the child was more capable than what the person expected. The child’s ability to engage with other children allowed the child to develop friendships and be involved in activities at their age level. 


Where we are today with early mobility devices 

Nearly 2 decades have passed since this new paradigm shift has occurred so why have we not adequately addressed the needs of infants and young children. Why might we still be resistant to accepting a new mobility device for infants and young children. I would ask you to consider this: the evidence clearly demonstrates that the ability to access one’s environment allows one to participate in life events. For infants, it contributes to learning and growing. Perhaps in the next few years we will have your stories of how mobility changed your child and your family. 


1.Wiart, L. & Darrah, J. (2002) Changing philosophical perspectives on the management of children with physical disabilities: Their effect on the use of powered mobility.  Disability and Rehabilitation, Vol 24. No.9, 492-498.

2.Wiart, L., Darrah, J., Hollis, V., Cook, A., & May, L. (2004). Mothers’ perceptions of their children’s use of powered mobility. Physical and Occupational Therapy in Pediatrics, Vol 24 (4). Doi:10.1300/J006v24n04_02

3.World Health Organization ICF. International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001


 

1.Wiart, L. & Darrah, J. (2002) Changing philosophical perspectives on the management of children with physical disabilities: Their effect on the use of powered mobility.  Disability and Rehabilitation, Vol 24. No.9, 492-498.

2.Wiart, L., Darrah, J., Hollis, V., Cook, A., & May, L. (2004). Mothers’ perceptions of their children’s use of powered mobility. Physical and Occupational Therapy in Pediatrics, Vol 24 (4). Doi:10.1300/J006v24n04_02

3.World Health Organization ICF. International Classification of Functioning, Disability and Health. Geneva: World Health Organization, 2001