DME

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Funding systems vary around the world, in our corner of the world both Australia and New Zealand have funding systems that are very function based.  Both funding systems require a person to have been diagnosed with a disability to access the system, however what equipment is provided is based on what a person needs to be able to do, it is not related to the person’s underlying diagnosis or medical based needs.  This means that in our funding reports we need to identify activities or tasks that a person wants or needs to be able to do, ideally something that can be measured through an outcome measure, and we link the features of the equipment to the relevant task.

However in the era of evidence based practice, finding evidence to support functional outcomes for equipment provision can be tricky, whereas more evidence is available to support medical benefits associated with equipment. 

What is a medical benefit?  Looking at the ICF, medical benefits are those that occur at a body structure and function level, as opposed to an activity or participation level.  Internationally, there are funding systems that are based on medical necessity, with the equipment that a person receives being linked to their diagnosis and resulting body structure and function limitations.

 

The presence of ‘medical necessity’ based funding systems has influenced the research surrounding wheelchairs and seating, with a number of research articles being available to support the medical benefits surrounding wheelchairs.  This information can be useful for therapeutic purposes but can be tricky to incorporate into a funding report that focuses on function. 

Are the medical benefits offered by a piece of equipment separate to the functional benefits?  Do we only mention the functional benefits in our funding reports?

Looking at the ICF can help answer these questions.  We need to remember that each of the ICF domains does not exist in isolation – each domain is linked or influenced by the other domains.  What we need to understand for a person is how these domains are linked, and how an intervention that may address an issue in one domain may influence factors in another domain. 

The one domain that can be hardest to address in a function based funding system is the body structures and function domain, despite changes in this domain having the potential to influence to both the activity and participation domains.  That said, some body structure and function limitations are easier to work through than others.   Maintaining range of movement or managing spasticity are two body structure and function issues that are regularly raised, with the link to functional tasks being easily established.  For example, regular standing helps a person maintain their range of movement in their lower limbs and this in turn helps maintain their ability to stand transfer in/out of their wheelchair, maintaining a standing transfer means they are able to continue to perform personal care tasks independently.   Or the ability to use tilt, recline and elevating leg supports in their chair helps manage their spasticity and hence maintain a seated position in their wheelchair, maintaining a seated position in their wheelchair means they are able use their eye gaze communication device reliably to successfully communicate with family and friends. 

Meanwhile other body structure and function limitations can be more challenging – for example bladder and bowel health.  Standing has the potential to positively impact on bladder and bowel health, however the research on this is a little more varied as bladder and bowel health is a more challenging area to research.  This doesn’t mean that you can’t incorporate this limitation into your funding reports, but it does mean that your clinical reasoning around this issue needs to be very robust.  For example, you may be working with a person who has frequent urinary tract infections (UTI) and the team are keen to explore power standing as a means of reducing these.  For this person multiple aspects need to be considered, such as

  • How is the frequency of UTIs related to the impairment/disability?
  • What medical options have been trialled and what is the outcome of these?
  • What functional impact do the UTIs cause?  Or how do the UTI’s impact on the person’s roles and responsibilities? 
  • What research is available to suggest that provision of this piece of equipment may be beneficial? 
  • Are there any potential contraindications for this person using this piece of equipment?
  • What are the potential implications if the piece of equipment is not provided?

Is it possible to work through all potential medical benefits to their impact on function?  Potentially not.  One challenging medical benefit to work through is bone mineral density, which is another benefit that is associated with standing.  Again we need to work through the above series of questions, however the answers to these questions may be challenging to incorporate into a funding report, with medical interventions potentially being more effective and low bone mineral density having a more obscure effect on a person’s roles and responsibilities.

Ultimately our funding reports require us to demonstrate good clinical reasoning and the process of justifying how an intervention at a body structure and function level impacts on the other ICF domains is another example of good clinical reasoning.  If you’re not sure how sound your clinical reasoning is in your report, it is good practice to get a peer or colleague to proof read your report before you submit it, ideally the person reviewing your report does not know the person the report relates to.  Having your reports peer reviewed can seem a little scary at first, however this review prior to submitting can save time in the process of getting a piece of equipment funded and help facilitate a good outcome for the person requiring the equipment.

Having trouble working through your clinical reasoning?  The education team is here to help, drop us a line at education.au@permobil.com and we can help point you in the right direction.

Wanting a place to start with research?  The RENSA position papers can help point you in the right direction.See here.  


 

Rachel Maher
Clinical Education Specialist
 
Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010. 
Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes. 
 
Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users. 

My most influential mentor once told me that the only pre-requisite for independent mobility is the motivation to move, a statement I have often reflected on and referred to throughout my career. There may be learning or training requirements to reach successful outcomes and specialised set up and inputs may be required but often the only way to determine if someone could use assistive technologies to enable independent mobility is by giving it a go!


Pre-conceived Ideology

We need to consider our own ideology and views and how these impact our decision-making processes around independent mobility. Society can perpetuate stigma and without us having successful experiences to draw on, these ideologies can influence our understanding of capacity. If someone is in an aged care facility, do we still consider independent power wheelchair access? Or is there an assumed capacity that someone will not have the cognitive ability to learn to safely operate a powered mobility option?

I am yet to find a cognitive assessment that definitively correlates to a person’s capacity for independent mobility. Do we consider that the resident may not want to spend the afternoon watching TV, that maybe they want to participate in other activities but require appropriate postural support to functionally engage?

It is not uncommon for an assessment intended to identify areas that require training for independent mobility are used to rule out independent mobility for an individual rather than to then provide areas to focus on for said training. Is this due to safety, to lack of time and resources? What level of clinical reasoning has been used in determining if the individual will be safe? Has the least restrictive option to independent mobility been considered if there are safety concerns?

There are also similar barriers for young children. Whilst we know from human development that children start to ambulate at around the age of 12 months, are we providing similar mobility opportunities to children of this age with mobility impairments? What about our children who are unable to verbalise a goal or desire for independent mobility, or present with challenging reflexes or limited active motor movement, do we consider ways they can be successful, have we provided opportunities to give it a go?


Joystick Access

There are many advantages to a joystick, the proportional function enables acceleration and directional control. A joystick is the standard access input for a powered mobility base and should be our first consideration for enabling independent control. Just because someone experiences some movement impairment in their upper limb doesn’t mean they will not have capacity to access using a joystick, however we may find that we need to modify the position, the location or the joystick knob.

We can also use the electronic programming to modify things such as the sensitivity, the acceleration or how far we need to deflect the joystick to action movement.


Position and Location

The mounting hardware that interfaces the joystick to the chair should have sufficient adjustment to enable it to be positioned further forward or back to enable us to adjust to the users’ individual requirements. You may also need to consider the arm support required in relation to the joystick position. A full-length arm rest may provide additional support but will limit how far back towards the user the controller can be positioned.

The height also needs to be considered, does the hardware enable fine tuning adjustment to raise or lower the control unit for best access to the joystick?

Non-standard mounting may be required to meet a user’s functional requirements. Midline controller mounting often provides better access and outcomes for developing children, the foot or chin may provide best access. Once you have identified how and where a user will access the joystick you can discuss options with your local product specialist.

Consider the user’s upper limb function, both gross motor and fine motor movements need to be considered, as too does strength and grip capacity.


Controller and Joystick

When considering a powered mobility device, we also need to consider the capacity and configuration of the input device, whilst there are many similarities between different manufacturers, there are also differences. What may work for one user may not work for another.

Consider visually – can the user see what they need to see or sometimes it’s around “hiding” or reducing what can be seen to reduce sensory overload.

Can the user access any buttons or switches, can we program in shortcuts or memory functions to make access easier? What hand function does the user have and is the joystick knob matching these individual needs? I was privileged to be invited to an event some years back with Ability Mate coined a toggle-a-thon. Essentially, this was a day where power wheelchair users who were struggling to operate their chair due to controller access came along and met with a designer. Together, they identified what issues they had and came up with a plasticine prototype. This was then assessed in relation to the users’ clinical requirements before a 3D joystick was printed!

This was then trialled and, if required, the design was tweaked and re-printed. It was a great example of a collaborative approach driven by the end user’s needs and the use of 3D printing for users who could utilise a standard controller with modified joystick. I have also used splinting material to mould a hand support and purchased small balls for gross hand grip in those rare cases where an off-the-shelf joystick knob has not quite met the specific required needs.

Switch Control

The advantages of a proportional control input method may be out weighted by fatigue of sustaining the deflection of the joystick or an individual may not have the required strength. It is important to consider both the type of joystick and the potential programming options in the first instance, but for some users switch control may provide the access required.

Proximity switches tend to require less movement to activate and are an important consideration when identifying switch access. The most common proximity switch control is through the use of a head array and this can be an advantageous method to consider for a child starting out with switch-controlled mobility. With the child turning their head towards the direction intended to move, the switch located in the head mounted pads activates.

With switch control, programming is also crucial. Switches can be latched or non-latched – think about a light switch, once you turn the switch on it remains on until you turn the switch off versus the switch only operational whilst you hold the switch down and sustain pressure on it. The switch hardware also differs with the amount of pressure required to activate.

As a therapist it is important to understand the user’s functional capacity to access and draw on your experiences or have an experienced therapist involved. Even working within a specialised seating service there are only a small proportion of wheelchair users that require complex alternative control set up so it is advantageous to work closely with a supplier or manufacturer experienced in setting up and programming the device.

When considering access to independent mobility, it’s often about giving someone an opportunity to trial and working through the process. For further information or to discuss a potential alternative input method for powered mobility, you can always reach out to our team at education.au@permobil.com where we can discuss some of the considerations and assist you with setting up a trial with one of our product specialists.


 
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 marks the start of the Tokyo 2020 Paralympic Games, giving us another chance to cheer on athletes from our own country and celebrate the achievements of athletes from around the world. 

This week also sees the launch of the WeThe15 campaign, a campaign striving to end the discrimination against persons with disabilities.  The number 15 relates to the reported percentage who live with a disability – 15% - resulting in 1.2 billion people worldwide.  Launching this campaign at the start of the Tokyo Paralympic games is deliberate, utilising the media coverage gained from this event to start a decade long campaign to increase disability visibility, accessibility and inclusion.   

WeThe15 brings the biggest coalition ever of international organisations from the worlds of sport, human rights, policy, business, arts and entertainment, a truly collaborative project to initiate change. 

In recent years progress has been made in breaking down stereotypes related to gender, ethnicity and sexual orientation, with the momentum for change now shifting to making disability at the heart of diversity and inclusion agenda.  WeThe15 aims to break down societal and systemic barriers that prevent persons with disabilities from fulfilling their potential and being active members of society. 

The majority of us who work in the health sector have some insight into what it means to live with a disability, we see the challenges that can arise due to a lack of mobility, or lack of vision or having a brain that does not function in a typical way.  However the majority of us only get a snapshot into a person’s life, once we finish our working day we go home to our own homes and activities and lives.   

What some of us may fail to identify is that the often uneventful lives that many of us live is often what a person with a disability is wanting to achieve – the right to live in their own home, to access their own communities, to experience joy and belonging just like everyone else. 

‘disability is not the most interesting thing about us’ 

‘we are the entrepreneurs, mothers, fathers, neighbours, friends’ 

In Australia and New Zealand, change is certainly in the wind at a policy level with funding relating to meeting disability related needs.  In some areas, a person with a disability has a greater level of choice and control in their ability to set goals and use funding to achieve these goals.  Achieving these policy shifts has taken some time and further work is required to achieve a balance between autonomy of the person with the disability and long-term sustainability of the funding, but it does represent a step in the right direction.  

Policy changes are only one aspect of the WeThe15 goal  change is also needed at a society level.  Challenges at a society level can be as simple as ensuring all people can access a building or as complex as the potential employers looking past a person’s disability when interviewing potential employees.  Again there has been progress towards making public buildings accessible and resourcing towards helping find employment, but as a society are we confident at ‘walking the talk’?   

Is inclusivity for all a goal that can be achieved?  The answer may lie with future generations.  In some areas, the quest for inclusivity can be seen in our schools, with all students having the right to attend their local school.  This has meant that a child with a disability can attend school with their peers in their own community, regardless of their needs.  For some, this has not been smooth sailing, with parents needing to work through pre-conceived ideas of the school team, however in the classroom and playground some heart-warming interactions can be seen - kids of all ages adapting a game so everyone can join us, kids accepting that another may need some quiet time or more time to complete a task, and kids just being kids – seeing the person before the disability, including some delightful conversations around some of the pragmatic aspects of a person’s disability. 

As a reader of this blog what can you do?  We can all lend our voices to the WeThe15 campaign to help raise awareness in our wider communities, lend our voices to the fact that each and every one of us is just a person, wanting to live a wonderfully ordinary, wonderfully human, life.  Let's all get involved!

Rachel Maher
Clinical Education Specialist

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

Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes. 

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

Sound clinical justification and rationale must be articulated when prescribing assistive technology – essentially, we need to demonstrate clinical reasoning processes to the funding body when seeking financial support for mobility and seating equipment. This can be challenging for newer prescribing therapists especially when the solution has not been determined through the clinical reasoning processes.

Whilst there is often a clear pathway between mobility needs and the requirement of a mobility base, it is often the other functional aspects of participation and activity that require additional features within the mobility base that need to considered prior to a trial.

What is Clinical Reasoning?

“Clinical reasoning is not new to occupational therapy. Therapists have always engaged in clinical reasoning, and educators have always sought to teach students how to think like therapists.” (Neisdiat, 1996). Clinical reasoning relates to the thinking and decision-making processes which take place in relation to clinical practice (Higgs and Jones 2000) It is the foundation for all occupational therapy interventions, a dynamic process that develops and evolves alongside our practice.

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

How Clinical Reasoning Develops

Dutton describes 5 levels of learning in relation to clinical reasoning development.  Let’s take a closer look at these stages and what that means in relation to equipment prescription in particular the trial.

Novice – This is our first experiences into clinical reasoning and is based on the foundation models and clinical principals that guide intervention. In other words, we understand the model or approach and potentially have the skills and theoretical concepts but will follow the model as rules, ask every question on the assessment form – eg. asking someone with a complete SCI at a mobility assessment  if they can walk because there is a box on the assessment form asking this question.

Advanced Beginner – This is the level of Clinical Reasoning we may have reached as a new graduate or in our first years of practice. Here we begin to modify rules and principles for specific situations (Dutton) – in other words, we begin to implement situational thinking but still need to develop how the assessment information is prioritised. Pre-trial assessment may have included components of the bio-mechanical MAT assessment of the joints that appear to be restricted – if someone can’t achieve full passive ROM in any of these joints it may still be viewed as a problem even if it is not impacting that person’s seated postural and functional needs. During the trial an advanced beginner clinical reasoner may identify potential issues for their client but rely heavily on the suppliers input to addresses potential options.

Competent – The competent clinical reasoner is able to adjust practice based on the situation. They can identify the relative importance of different pieces of information about a client but may still have difficulty altering the intervention plans or seeing how changes will impact on posture. In a trial they may experience difficulty in understanding the impact of different sized chairs between the trialled option and the prescribed size or configuration. The clinical reasoning may have been (as it should) prior to the trial but at the trial itself they may struggle to making a decision that modifies the anticipated outcome.

Proficient – The proficient therapist has the flexibility to alter plans as needed throughout the process or intervention. The proficient therapist can easily identify how configuration can impact on the access and functional mobility and can trial slightly different size or configuration and still identify features to ensure best outcomes even if the exact set up is unavailable to trial. They can articulate clinical justifications based on the assessment and observations from trial.

Expert – The expert prescriber tends to take cues from the client rather than needing to follow a set plan. They can make on the spot changes to the initial plan and can identify and adapt information to reach best outcome. Experts are able to recognise client problems and potentials quickly on the basis of their recognition of patterns from previous clinical experiences.

“It is not reasonable to expect occupational therapy students to graduate as competent, proficient, or expert therapists. Those levels of clinical reasoning require years of clinical practice and continuing education”
Neistadt

We move through these stages as our clinical skills develop, based on our experiences and level of reflective practice. If working within different scopes, we may also demonstrate different levels of clinical reasoning for different areas of practice. Time taken to work through the stages varies within scopes and complexity.

When we conduct a seating and mobility assessment we apply clinical reasoning to determine potential options. There is a major difference in the funding processes between New Zealand (NZ) and Australia. In NZ, the clinical justifications are submitted based on the clinical assessment, potential solutions that meet the clinical needs are identified. Once the funding body has determined that the clinical justifications meet criteria, approval is given to trial the specific equipment the therapist has identified.

In Australia the system remains that the funding application is submitted after the trial. Regardless of where in the process the clinical justification is submitted to a funding body, the assessment and trial still have the same purposes and follow the same processes. The clinical reasoning process begins as we collect information and complete our evaluation and guides us to the selection of specific equipment parameters.

The clinical justifications and equipment parameters should be determined before a trial. The purpose of a trial is to confirm specifics around those features and ensure the expected outcomes are met. Evidence of how the outcomes are met come from the functional tasks completed at trial.

For those therapists that are at the early stages of prescription experience, there are lots of opportunities to develop your clinical reasoning; ongoing education, supervision, mentorship and experience. For the more experienced therapists, having a student on placement or providing mentorship can not only assist our newer therapists but assist in your own clinical reasoning development. Our Permobil education team are here to support you so if you want further support, please don’t hesitate to reach out to us at education.au@permobil.com


References

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

The development of clinical reasoning follows a continuum through the following stages: novice, advanced beginner, competent, proficient, and expert (Benner, 1984; Dreyfus & Dreyfus, 1986; Dutton, 1995; Slater & Cohn, 1991).

Neistadt, M (1996) Teaching Strategies for the Development of Clinical Reasoning. American Journal of Occupational Therapy, September 1996, Vol. 50, 676-684.


 
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.

 

What is a cost effective solution?  

Cost effectiveness is something we need to consider when recommending equipment for a person, but what exactly is cost effective solution? 

cost effective solution is not necessarily a low cost solution, or the cheapest solution of a particular type of equipment.   When considering whether an item is a cost effective solution we do need to consider the initial purchase price, but we also need to consider a range of other factors, for example the features that a product offers (and how these relate to the identified goals), the materials the product is made from and the ongoing cost of maintaining and repairing a product.  For this blog we are going to look at wheelchairs in particular, however these ideas can be applied to other pieces of equipment. 

As part of establishing what is a cost effective option we need to consider the person using the chair and where the chair will be used.  We need to consider whether the person’s needs are stable and the chair will be used in its original configuration for quite some time, or whether we are looking at a teenager who is going to grow out of their chair within a reasonably short period of time or perhaps a person with a progressive condition who may need their chair adapted as their needs change.  We also need to consider where a piece of equipment is going to be used – is it going to be used mostly indoors with occasional outdoor use, or will this person be using their chair extensively outdoors, and is this outdoor terrain flat or are there hills?  These factors can help us determine how durable a solution needs to be and whether we need a solution is adaptable to changing needs over timehelping maximise the length of time a chair can be used by the person. 


When looking at chair options we also need to be mindful of how chairs are promoted and their reported capability, in particular modifications to increase functionality of the chair.  We need to be wary that because a modification can be done, it doesn’t necessarily mean that it should be done, pushing a product past its intended use typically results in issues at some stage, either poor functioning in the short term or repair and maintenance issues in the long term, ultimately defying the intent of providing a cost effective solution.  An important aspect to consider on all equipment is what the safety parameters are on a product, for example lock out parameters on a power wheelchair are in place to keep a person safe while using their chair, over riding these to increase the functionality of a chair is never a good idea.
   
Looking at manual wheelchairs – the materials used in these is an important consideration.  The two common materials we see are titanium and aluminium both of these are strong lightweight materials, however they have different life spans – with titanium being more durable and the higher cost option.  What does this mean for cost effectiveness?  For wheelchair users that use their chairs full time and whose needs are stable, a titanium frame is typically a cost effective option as it a robust solution that will last a number of years, with the frame often having a lifetime warranty and the componentry being the part of the chair that requires attention over time.  However for a person who’s needs are likely to change over time, due to growth or a change in functional ability, they may not use the manual chair long enough for a lifetime warranty to be relevant, hence an aluminium frame is likely to be the more cost effective option, with the person changing chairs before the aluminium frame is at risk of failure.  Where does carbon fibre fit into the cost-effective equation? Carbon fibre tends to be a higher cost option, but it can also be the lightest option of the three, and may prove to be the cost effective option for other reasons, for example if provision of a very lightweight chair means vehicle modifications are not required.  The big consideration with carbon fibre is that a wheelchair user needs to treat it with care, so is only a cost effective option if they are given to the right person.

Establishing cost effectiveness for power wheelchairs can be a little trickier, as we need to ensure we are comparing apples with apples.  Power wheelchairs range in their complexity, purchase cost and ongoing repair and maintenance costs.  A good place to start is to establish what features a person needs in their power wheelchair and then establishing which models fit these specifications, considering aspects such as power seat functions required, power wheelchair performance and what a person’s long term needs might be.   All power wheelchairs have their benefits and their challenges, and we need to ensure that we match these benefits and challenges to the wheelchair user.  Often this process results in a couple of chair options being identified, however sometimes we are faced with the dilemma of do we upgrade to ‘future proof’ the chair (at an additional cost) or do we go with the chair that meets the needs of the person now? 
 
Often, we have a gut instinct on whether we should consider upgrading a chair, however finding the words to justify the increased cost for an upgrade can be a challenge.  This is where consulting with other team members can be helpful, for example consulting with the wider multidisciplinary team if a person has a progressive condition to establish the rate a person’s functional abilities are changing, and hence what wheelchair features may be required in the medium term, then establishing whether it is more cost effective to provide these features now or whether it is something that is cost effective to provide later, such as retrofitting of power seat functions.  If we are considering power wheelchair performance, discussing what demands will be placed on the chair with a technician or dealer can be helpful, this can help align the more technical aspects of a chair with the needs of a user, for example whether 500W motors are going to be a better option than 300W motors for the person who needs to travel up a hill to work each day.
 
One last aspect of cost effectiveness doesn’t relate to the chair at all, which is the effect on the persons environment.  The subtle differences between chair specifications can cause significant ripple effects through other parts of a person’s life, for example a 1” increase in seat to floor height or in overall width can make the difference between a person accessing their modified vehicle, or not.  The decision between a power wheelchair and power assist can be influenced by a person’s home environment and what changes may need to be made to accommodate a larger power wheelchair base.  Or provision of an additional power seat function can result in maintaining, or even decreasing, the level of a support a person needs to function.
 
Establishing whether a solution is cost effective can be tricky with many different aspects to cover, please feel free to reach out to our team if you are wanting to discuss a solution further on education.au@permobil.com 
 

Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.
 
Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.
 
Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users.

 


Cognitive load theory is a theory of how the human brain learns and stores knowledge. When our brains process and store information, it takes place in one of two ways.

One way, known as our working memory, is where small amounts of information are temporarily stored. Scientists believe that at any one time our working memory has the capacity on average to store up to four pieces of information e.g. reply to the email I received earlier today, listen to the voicemail and return the call, finish the article for the blog and pick up the dry cleaning on my way home.

The second is known as long term memory. In this type of memory, larger amounts of information are stored for long periods of time. Some information sticks around forever, some we eventually forget. What we continue to ‘know’ is dependent on not only how often we use this piece of information, but also how it was stored in the first place.

The ability of our brains to recall information from our long-term memory is determined by ‘schemas’. A schema is a group of linked memories, words or concepts and become a cognitive shortcut. This leads to having the ability to store new things in our long-term memory and therefore being able to remember and retrieve this information in the future, is much quicker and more efficient.  

 


Sometimes, when we are learning, you’ll hear people say, or perhaps you have said something similar yourself “I’ve read this over and over again, I just don’t get it, my brain hurts!” 

This is a concept known as cognitive load, which describes that our brains have a limit to how much information can be in our working memory at any one time. If a learner, or a teacher or presenter can be mindful of this and present information in way which does not overload the learner, only offers up necessary, usable chunks of well explained information, it reduces cognitive load, which allows the learner to move the information into long term memory to create the schema. 

Cognitive load theory and research has made several recommendations regarding instructional techniques that can be used when teaching. One suggestion is coined the ‘redundancy effect’.

“Students do not learn effectively when their limited working memory is directed to unnecessary or redundant information. The ‘redundancy effect’ occurs when learners are presented with additional information that is not directly relevant to learning, or with the same information in multiple forms.

An example is a textbook which includes both text and a diagram that needlessly repeat information, or a PowerPoint presentation in which the presenter reads the text presented on the screen. Requiring learners to process redundant information inhibits learning because it overloads working memory. Cognitive load research shows that best practice is to remove redundant information from learning material.” See here for further information.


The Permobil Education Team deliver education using a variety of methods, such as:

  • face to face – classroom style teaching 
  • hands on demo, practical and theory 
  • written material in the form of a blog or instructional guides 
  • online education presented either as a live or recorded webinar or via Microsoft Teams 

With cognitive load being front of mind, we considered some alternatives which has resulted in the launch of our new and additional format for delivering education – Permobil Express Learning!  

 


We have created our first express course, each module is only 10-15 minutes in length, meaning we only cover what you need to know without all the other fluff!   

Our first course for 2021 consist of 10 express modules and is titled – Seating and Positioning Needs of the Aged Care Population.   

We begin with laying the foundations with an overview of the healthy skin followed by the ageing skin. We cover postures and the impact on the seated individual in relation to their ability to function, before delving into risk factors contributing to wound development. We focus on pressure injury risk and classification, along with other causes of skin damage. Then we wrap up the course with two express modules covering the recommendations and types of support surfaces available.

Click here to find out more and to register for our upcoming Express Learning Course. 


 

Dee Smith
Clinical Education Specialist

Dee is a Registered Nurse with almost 25 years’ experience in a variety of specialties and is passionate about mentoring, educating and empowering health care professionals to provide safe and quality care.

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

Dee worked within the Aged Care Industry as a Clinical Nurse Consultant in Infection Prevention & Control. She developed and delivered education and training of evidenced-based practice in Infection Prevention and Control, Wound Care and Pressure Injury Management. 

Dee joined Permobil in 2020 as the Seating and Positioning BDM and in 2021, joined the Asia Pacific Clinical Education team as Long Term Care/Aged Care Clinical Specialist. 

The Olympics are due to start in a few weeks followed by the Paralympics. This year's event is due to take place in August in Toyko, Japan, after having been postponed due to the global pandemic which prevented them going ahead last year as planned. Some believe the Paralympics were so named as a joining of the words paraplegia and Olympics, in reality they are so named because the word “Paralympic” derives from the Greek preposition “para” (beside or alongside) and the word “Olympic”. Paralympics are the parallel Games to the Olympics and the two movements exist side-by-side.

Whilst the first Olympics have a long history that we learn about in primary school, less is known about the Paralympic movement. 

Following World War II, the British government opened a spinal injuries centre at the Stoke Mandeville Hospital, and in time, rehabilitation sport evolved to recreational sport and then to competitive sport. On 29 July 1948, the day of the Opening Ceremony of the London 1948 Olympic Games, Dr. Guttmann - who started the spinal centre - organised the first competition for wheelchair athletes.  This event was named the Stoke Mandeville Games and involved 16 injured servicemen and women who took part in archery. The Stoke Mandeville games went on to become an international competition in 1952 when a group of Dutch ex-service men joined the event.

In 1960 the Stoke Mandeville games became the Paralympics, with 400 athletes competing in the Rome, Italy games. The Paralympic Games have been run next to every Olympic Games since then. That same year an ‘’International Working Group on Sport for the Disabled’ was set up to study the problems of sport for persons with an impairment, this group went on to become the International Sport Organisation for the Disabled (ISOD) and advocated for the inclusion of athletes with a range of impairments to be included in the games. Other groups advocating for sport later joined ISOD and formed the International Co-coordinating Committee Sports for the Disabled in the World" (ICC) in 1982. Seven years later the International Paralympic Committee (IPC) was founded as an international non-profit organisation in Dusseldorf, Germany, to act as the global governing body of the Paralympic Movement.

So how do the Paralympics be inclusive and fair for athletes with different impairments? Classification. “Classification is the cornerstone of the Paralympic Movement; it determines which athletes are eligible to compete in a sport and how athletes are grouped together for competition. In Para sports, athletes are grouped by the degree of activity limitation resulting from the impairment. This, to a certain extent, is similar to grouping athletes by age, gender or weight. Each sport has its own classification system and code that reflects the specific requirements for that sport. Initially classification was medically based on the athlete's diagnosis, but has evolved into a functional classification system. Wheelchair rugby is one of the most popular Paralympic sports and one of the first to develop a robust and evidence based functional classification system.

Wheelchair rugby is played on a court. It is a fast and high impact game and popular spectator sport. A wheelchair rugby team consists of up to 12 players however there are only ever 4 players per team on the court at one time. Each athlete is classified into one of seven sport classes based on their functional capacity. Each class has a number value from 0.5 to 3.5 (0.5 being the class with athletes with most impairment), where the added value of these numbers determines who can be on court playing at any time - the total value cannot exceed 8.0 per team. Over the years that I have been involved in Paralympic sport, I have seen first-hand how hard our athletes train and work to overcome a multitude of barriers; physical, emotional and financial to make the national teams and represent their country. You can find out more about wheelchair rugby at IWRF Wheelchair Rugby Ready the official ruby federations page.

Pool draw for wheelchair rugby at this years Paralympics.

We would like to wish all the Athletes competing this year the best of luck. Follow our Facebook and Instagram pages for updates on our Permobil ambassador competing and general news from the games. We will be closely following and supporting you all.

Tracee-lee has been involved with wheelchair rugby classification in Australia and New Zealand and has been part of international classification panels in Asia, USA and Europe. She also trained in Boccia classification.

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.

To change or not to change.  When MWD (mid-wheel drive) chairs prove challenging


A frequent conversation I’ve had in recent weeks has been around drive wheel configuration and working out what drive wheel configuration may best meet a persons needs.    

In this part of the world we frequently prescribe mid-wheel drive (MWD) power wheelchairs, with their manoeuvrability working well in a variety of indoor spaces and improvements in suspension making them more user friendly outdoors, making it a chair that can meet an assortment of needs. But sometimes a MWD chair doesn’t work as well as we hoped and we are left trying to problem solve whether we can adjust the chair to make it work, or whether we look at whether another drive wheel configuration might work better.
 
Some of the common issues that get raised with MWD chairs include difficulty positioning a person’s feet, the person reporting the chair is difficult to use outdoors, or that using the chair outdoors impacts on their sitting tolerance.  Sometimes these issues can be improved by a change of set up, but other times it is the limitations of a MWD chair coming into play.
 
Let us start with looking at drive wheel configuration and castorsas the different base configurations have their benefits and challenges.  A front wheel drive (FWD) chair has the drive wheel at the front and two trailing castors, this arrangement lends itself to good outdoor performance as the front drive wheel can easily climb small obstacles.  Historically FWD chairs were prone to ‘fish tailing’ making the chair challenging to drive at faster speeds, however this has been overcome with improvement in drive tracking technology.  Some FWD chairs may have small anti-tip wheels on the front depending on their speed setting or power seat functions used on the chair.
 A MWD chair has its two drive wheels in the centre of the chair, with two castors sitting in front of the power wheelchair base and two castors at the rear providing stability to the base.  Advancements in MWD technology have resulted in improved suspension, a feature of this being castors that have some ability to rise and fall, helping overcome the historical issue of ‘high centering, or when the drive wheels become suspended when the chair traverses a steep road crossing.
 
Rear wheel drive (RWD) chairs have the large drive wheels towards the rear of the chair with two castors at the front, these chairs tend to be the easiest chairs to drive at higher speeds,but have a larger turning circle making them more challenging to use indoors.  Historically RWD chairs have been popular with users who frequently drive their chairs outdoors.
 
Remember also that where the drive wheel is positioned also impacts on how the chair moves. Many users will have a drive wheel configuration preference based on how the chair drives and how well this works in the environments they need to access.
   
Coming back to some of the commonly encountered MWD issues.  For wheelchair users who sit with their feet spaced apart, perhaps due to limitations in joint range of movement or oedema, how wide their feet can be positioned in a MWD (or RWD) chair is limited by the width between the two front castors.  For some users, the position of their feet is simply too wide for them to sit between the two castors, while others they may have issues with the front castors knocking their ankle when turning, or they have difficulty keeping their feet on the footplate – placing them at risk of injury if their foot gets caught between the footplate and the front castor.  For users who are hoist transferred and have good hamstring range, using 70 degree swing away hangers may overcome this problem, however for those who stand transfer in/out of their chair, changing to a FWD option may work best, however you may be limited by what power seat functions you use if you want to avoid the anti-tips wheels at the front.
The second issue that is often reported is the user reporting that using the chair outdoors increases their pain, or their tone increases resulting in a loss of positioning.
 
Simple but sometimes effective ways to improve ride quality can be to look at a person’s seating (air or gel based seating may offer benefit over foam) or swapping solid tyres out for pneumatic, but sometimes it is the two extra castor wheels in contact with the ground that is causing the issue.  When a chair encounters a small obstacle, how the chair responds depends on its drive wheel configuration.  Thinking about something like a low threshold to enter a home, for a RWD or FWD chair, only two sets of wheels need to manage the thresholdwith the first set of wheels heading up and over then the second set following, much like how a standard vehicle would manage such a threshold.  For a MWD chair managing that same threshold, the front castors would rise up and over the threshold, then the drive wheel (which is positioned under the user) and then the rear castors, this has a very different feel for the user, and for some users this subtle difference can be enough to cause issues.  When looking at base options for ride quality, don’t forget about your suspension options – not all suspension is created equal, and suspension options vary between model of chair. 
 

A third and less common issue that can arise with a MWD chair relates to where a user’s weight is distributed on a chair and how the chair performs, particularly outdoors.  On a MWD chair the user’s weight ideally needs to be distributed over the power wheelchair base  with their pelvis positioned either above or slightly behind the drive wheel. 

For children and people of short stature, it may not be possible to position them over the drive wheel as their thigh length is too short, meaning they sit towards the front of the chair.  For this group of people, a MWD chair may feel more like a RWD chair to drive, as the drive wheel is positioned behind them, or it may be that the chair struggles to get traction on softer surfaces such as grass or gravel as the person’s bodyweight is towards the front of the chair, not down through the drive wheel.  Changing to a front wheel drive can help overcome these issues and can also result in a base that has a shorter footprint which can be more in keeping with the person’s size.

For adults, their bodyweight may be focused towards the front of the chair for a couple of different reasons.  If a person has shortened hamstrings, they may be positioned towards the front of the seat pan to keep their feet away from the power wheelchair base itself, meaning their pelvis is sitting in front of the drive wheel.  Or it may be that the person has significant lower limb oedema and carrying extra fluid in their legs, or has extra body weight that is carried in front of them, so while their pelvis may be in line with the drive wheel, their body weight is distributed towards the front of base.  In these situations, having extra bodyweight towards the front of the chair can mean the suspension on the front castors is already loaded by the person’s bodyweight, hence when the chair is used outdoors, the castors have a limited ability to move and hence road crossings can become more challenging.  For some chairs they may also be more sluggish to turn on carpet, as more force is required to turn the castors which are carrying more load than intended.  Changing to a FWD chair typically overcomes these issuesas the drive wheel is now positioned where the castors previously were, with the drive wheel being more suited to carry this load.  As a side note, positioning a person towards the front of the seat pan can also influence how the power tilt actuator functions on some chair models, with the actuator prone to early failure if the setup is not ideal.  

Not sure if one of these situations is relevant to a person you are prescribing a chair for?  

Reach out to your local technician/dealer/supplier and seek a second opinion, with a front and side on photo of the person in the chair to share if possible.  Getting the drive wheel configuration right for a person can make a big difference in how well a power wheelchair functions for a person, maximising their mobility and what they are able to achieve. 


  

Rachel Maher
Clinical Education Specialist

Rachel Maher graduated from the University of Otago in 2003 with a Bachelor of Physiotherapy, and a Post Graduate Diploma in Physiotherapy (Neurorehabilitation) in 2010.
 
Rachel gained experience in inpatient rehabilitation and community Physiotherapy, before moving into a Child Development Service.Rachel moved into a Wheelchair and Seating Outreach Advisor role at Enable New Zealand in 2014, complementing her clinical knowledge with experience in NZ Ministry of Health funding processes.
 
Rachel joined Permobil in June 2020, and is passionate about education and working collaboratively to achieve the best result for our end users. 
 

How to set up a ROHO® QUADTRO SELECT® Cushion

 

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

What is a QUADTRO SELECT® Cushion? 

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

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

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

What is the ISOFLO® Memory Control? 

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

ISOFLO Memory Control shown in the OPEN position.

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

ISOFLO Memory Control shown in the CLOSED position.

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

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

 

Why does the ISOFLO® Memory Control look different?

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

Before Re-Design

After Re-Design

 

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

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

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

How to set up a ROHO® QUADTRO SELECT® Cushion

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

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

 

 

 

 
Dee Smith 
LTC / Aged Care Clinical Specialist  

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

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

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

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

Can attendance at an Expo count towards ongoing professional development?  


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

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

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

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

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

Melbourne - Tuesday 17 May 2021

Melbourne - Wednesday 18 May 2021

Perth Wednesday 26 May 2021

 

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

Tuesday 6 July 2021

Wednesday 7 July 2021

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

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

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


 

Tracee-Lee Maginnity
Clinical Education Specialist 

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

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