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The end of 2021 is almost upon us, and hopefully for many of you the end of year rush is slowing down and everyone is looking forward to some time off with friends and family over the holiday season. 

I think it is fair to say that 2021 was not the year we were expecting in this corner of the world, many of us started the year full of hope that it would be a ‘better’ year, with some areas even being able to enjoy concerts and sports events, however the Delta variant reminded us that we are still in the midst of a global pandemic and pushed us back into the realm of lockdowns and uncertainty. 

For some, lockdowns have given us opportunity to re-evaluate what is important in life – a chance to slow down and spend time with the kids, to get outside and move our bodies or to get creative in the kitchen, however for others it was a time of increased stress of juggling work and children home from school.

The therapy professions are often based around ‘helping’ other people – helping people recover from an injury or illness, helping a person obtain equipment to maximise their independence or helping a person work towards achieving a desired goal.  But do we take steps to help ourselves?  Do we set goals for the things we want to achieve?  Potentially goals to improve our own mental and physical wellbeing? And do we implement strategies for ourselves to ensure we achieve our goals? – this is usually the hard part!

Most of us will be familiar with SMART goals – goals that are specific, measurable, achievable, realistic and time bound, but simply ensuring our goals are SMART might not be enough to help us achieve our goal. What else do we need to consider to ensure our goals are more than wishful thinking?  The goal setting literature makes for interesting reading, with lots of little tips and tricks that may increase the odds of us achieving our goal. 

Things to consider

  • Is the goal you are wanting to achieve your own goal?  One that is meaningful to you? 
  • Are your goals ambitious but attainable?  Do we set goals that not only push us but have us feeling good when we achieve them?
  • Do we set goals for the things we want to do, not the things we don’t?  While a goal such as ‘I am going to read a book in the evening’ may not be that different from ‘I don’t want to go on social media in the evening’, the reality is our brains process these goals differently
  • Do we set an action plan as to how we are going to achieve this goal? Have we identified the practicalities of where, when and how we are going to work towards our goal?   (tip – an action plan is best reviewed weekly)
  • For the times when your action plan gets turned upside down – do you have a ‘coping plan’ to help when your usual routine gets disrupted? 
  • And lastly, what is your goal orientation?  Do you have a mastery mindset or a performance mindset?  I must admit I had to explore this concept further to fully understand the difference.

Mastery goals are goals that we set in which we compete with ourselves – these goals are typically characterised by us seeking out challenges and maximising our opportunities for leaning.

Performance goals are primarily motivated by external feedback, or where we are striving to demonstrate our competence relative to others.

Mastery goals tend to support perseverance and a desire to learn, with failure to achieve the goal leading us to reflect on where we could improve and the resilience to then try again.

Written in this light, we can see how mastery-based goals are what we should be aiming for, and while our goals may start out mastery-based, it can be easy to slip into a performance based mindset.

For example, last year I took up playing squash, with the goal of having one scheduled activity a week that got me out of my home-based office. Season one: goal achieved.  Season two, as my ability to play squash improved, the competitive side of me came out and the goal slowly evolved to wanting to win each game – so play better than my opposition (a performance-based goal). Obviously all was well when I won the game, but I must admit there were weeks when I was beaten and left feeling deflated as I hadn’t ‘achieved my goal’. 

After a series of losses I was left wondering why on earth I was persevering with this sport, when some encouragement from a fellow player lead me to reconsider my approach (and remember why I was there in the first place).  Changing my goal to ‘I need to maintain my focus on the ball’ and ‘I need to position myself to better hit the ball’ (mastery-orientated goals) meant how I felt after the game was based on how I played, not whether I won or lost. 

Why do we slip into a performance mindset?  Perhaps it is our tendency as humans to compare ourselves against others, despite knowing that doing so tends to make us more unhappy if we find ourselves wanting.  Maybe we stop working towards a goal when we become aware of how slow we are to improve on a skill relative to others, forgetting why we set out to learn the skill in the first place? 

The start of a new year can be a good opportunity to stop and reflect on the year that has been and look forward to the year ahead, thinking about what we want to achieve for ourselves and give consideration as to how we might get there.  We need to remember that when we are setting our own goals we want to ‘play our own game’ – identify a challenge that is meaningful (and challenging) to us, make a plan based on what we can manage, and base our success off criteria that are intrinsic to us. 

To those who are reading this – the therapists, the end users, the dealers, our own Permobil team, it is never too late to learn something new, try something new or go somewhere new – I challenge you all to identify something you would like to work towards in 2022, maybe even set a goal to help you get there.

 

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.

 

 

 

Over the past 100 years attitudes towards people with disabilities and inclusion have drastically improved, however, people with disabilities continue to experience marginalisation and disproportionate disadvantages. There have been multiple movements that have precipitated these changes including deinstitutionalisation, which began in the 1950s, the Paralympic movement, and increased advocacy and rights supported by various acts and legislations.

In 1992, the UN proclaimed an annual “International Day of People with Disabilities” (IDPD). Whilst this day has been observed annually for almost 30 years, International Day of People with Disabilities is more than just an annual day, but a movement used to break down barriers to inclusion and advocate for the rights of people with disability.  One important aspect of this movement is that it includes persons who themselves have a disability – ‘Nothing about us, without us’. 

In 2021, IDPD, also known as IDPWD, will be observed on December 3rd and the theme for the 2021 day is “Leadership and participation of persons with disabilities toward an inclusive, accessible and sustainable post-COVID-19 world.” Whilst so many people globally have continued to be impacted by the Covid pandemic, one of the key messages published by The World Health Organisation (WHO) is that “COVID-19 has resulted in further disadvantage and increased vulnerability for many persons with disabilities due to barriers in the health and social sectors, including discriminatory attitudes and inaccessible infrastructure” International Day of Persons with Disabilities 2021

IDPWD is a day for

  • Celebration – to recognize and value the diversity of our global community, and to cherish the role we all play, regardless of our abilities.
  • Learning – to understand and learn from the experiences of people with living with a disability.
  • It is a day for optimism – to look towards the future and the creation of a world where a person is not characterised by their disabilities, but by their abilities.
  • Action – where all people, organisations, agencies, and charities not only show their support for International Day of People with Disabilities, but take on a commitment to create a world characterised by equal human rights International Day of People with Disabilities

IDPWD is also an opportunity to remind everyone of The Convention on the Rights of People with Disabilities (CRPD), an international human rights treaty of the United Nations intended to protect the rights and dignity of people with disabilities.   The CRPD has eight guiding principles, including ‘full and effective participation and inclusion in society’  and ‘respect for difference and acceptance of persons with disabilities as part of human diversity and humanity’, principles that resonate with many of us involved in the disability sector.   

Per Udden, Permobil’s founder embraced mobility as a human right, and this has underpinned the values that Permobil was built on. 

  

Here at Permobil we believe that it all starts with our wheelchair users.   Our wheelchair users  are the experts in their needs and the unique challenges they face in daily life, hence we value the input and perspectives they bring, influencing our interactions and product development.

Today, Permobil’s Core values continue to build on this initial philosophy and provide guidance that align with IDPWD.

 

 

These core values influence how we work as a company – from ensuring an inclusive workplace, to bringing our passion into what we do from our warehouse team to our sales team and across the company, and by designing products focused on the user wants and needs.

We hope this day will inspire you to celebrate, learn and take action to bring about a more inclusive environment for everyone. 

For more information on International Day of People with Disabilities

United Nations - Link 

Convention on the Rights of Persons with Disabilities (CRPD) - Link 

International Day of People with Disability – Australia - Link 

New Zealand Disability Strategy - Link 

 

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.

 

 

Thursday 18th November is the world-wide STOP pressure injury day, a day designated to increase awareness about pressure injury prevention – for both health professionals and the public. Word-wide STOP pressure injury day started in 2012 following a meeting of Spanish speaking wound care organisations, with the European Pressure Ulcer Advisory Panel later joining and encouraging other countries to participate.

The aim of the day is to raise awareness of pressure injuries and how to prevent them. Key messages are:

  • with the right knowledge and care, pressure injuries can be avoided.
  • all health professionals, carers, family/whanau members and patients have important roles to play in prevention.
  • skin care matters.

World-wide STOP pressure injury day may be a recent initiative; however, pressure injuries have been with us for some time – albeit under an assortment of names. Looking at an article by Agrawal and Chauhan (2012), pressure injuries have been recognised as a disease entity since the early ages  - evidence of pressure injuries have been found in Egyptian mummies, some of which are more than 5000 years old. 

Hippocrates (460-370 B.C) had described pressure injuries in associated with paraplegia with bladder and bowel dysfunction, while in the 16th century a French army barber-surgeon wrote about a wounded French aristocrat developing a pressure injury that was later healed with good nutrition, pain relief and debridement.

In the 19th century Jean-Martin Charcot hypothesized that pressure injuries were related to damage of the central nervous system, where he classified pressure injuries into decubitus acutus, chronicus and ominosus. The classification of decubitus ominosus was given asCharcot observed that many patients who developed eschar of the sacrum and buttocks died soon afterwards. Brown-Sequard opposed Charcot’s theory and proved that if pressure is avoided in guinea pigs with spinal cord injury, a pressure injury can be avoided or an existing pressure injury healed.

An article by Levine in 2019 discussed the role of orthopaedic surgeon and spinal injury specialist J. Darrell Shea, who proposed a sequential four stage decubitus classification system in 1975, from which the current staging guidelines have evolved from. This was not the first attempt at a pressure injury staging system, with earlier classifications systems proposed by Guttman and Campbell, with Guttman linking treatment plans to each stage and Campbell acknowledging the need for surgical management for advanced stages.

Interest in a staging system accelerated in the mid-20th century because of World War II casualties, which included thousands of men with paraplegia and spinal cord injuries. Medical developments during the war increased the number of severely injured casualties surviving the battlefield, with advancements in surgical techniques resulting in the first report of surgical closure of a decubitus ulcer (with the aid of penicillin) being published in 1945. The post war years saw several publications appear in regard to pressure injury treatment, in particular treatment of pressure injuries in young males.

Shea proposed a simplified four stage system or pressure injury progression, with acknowledgement of the role that friction and maceration play in addition to pressure. Like earlier systems, each grade was linked to specific treatment recommendations. Shea also recognised that pressure injuries could start at either the surface, or deep within tissue adjacent to the bone – using the term ‘closed pressure sore’ - which we now classify as a deep tissue pressure injury. Shea’s proposal for a sequential four-stage system was an attempt to better understand and treat pressure injuries, stating that ‘one cannot properly treat a lesion that is not well understood’.

Shea’s grading system was adopted and modified by the National Pressure Ulcer Advisory Panel and distributed in 1992. Over time we have further increased our understanding of pressure injuries, including a wider range of populations (such as critical care and geriatric populations) and the role that aging and chronic disease play.   Our increased understanding on pressure injuries have resulted in the staging system evolving over time, including how the staging system is meant to be used and factors we need to consider when devising a treatment plan.

Today the majority of us have ready access to a wide range of resources for pressure injury prevention and management, with a large amount of information captured in the International Guidelines.   The International Guidelines represent a collaboration of the Pan Pacific Pressure Injury Alliance (PPPIA), the European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Injury Advisory Panel (NPIAP), resulting in a resource that is evidence based and easy to access – with hard copy or e-book options readily available. Last year a smart phone app was launched, allowing evidence-based recommendations to be available at our fingertips. If you are interested in the procedure as to how the Clinical Practice Guideline was updated, the article can be found here.

For world-wide STOP pressure injury awareness day, we have compiled a list of resources available around our region, but a resource in particular I would like to single out is the patient stores from the Health, Quality and Safety Commission in New Zealand.  As health professionals we have an understanding of what a pressure injury can mean in terms of length of stay in hospital, or what equipment a person may need, or what additional care support a person might need at home, however the patient stories bring home the reality of what it means for the person when they get a pressure injury, in particular the isolation that comes from extended bed rest or the practicalities of managing such a wound. Further information on these case studies can be found here.


Pan Pacific Resources

The Pan Pacific Pressure Injury Alliance is made includes Australia and New Zealand as members with Japan, Korea, and China as associate members. Learn all about it here.

Resources you might like to explore on the PPPIA website

  • 2019 International Guideline here. 
  • Pressure Injury flowcharts here.
  • The Official Pressure Injury Prevention Guideline App here.
  • PPPIA - Classification Images for different skin tones here. 

 Permobil have collaborated with PPPIA to produce Wheelchair Seating Pocket Guide 


New Zealand Resources

  • New Zealand Wound Care Society here.
  • ACC resource page here.
  • Case Studies in New Zealand here.
  • New Zealand Spinal Trust - Importance of skin checks here.

Additional Resources


Pressure Injury Risk Assessments


Blog References

Agrawal, K. & Chauhan, N. (2012) Pressure ulcers: Back to the basics. Indian J Plas Surg 45(2) 244-254 doi: 10.4103/0970-0358.101287

Levine, J. (2019) Historical Perspective on Pressure Injury Classification: The Legacy of J. Darrell Shea. Advances in Skin & Wound Care 32(3) 103-106


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. 

 


October is Spina Bifida Awareness Month, and like all awareness months it is a good opportunity to learn something new.  For me, it has been some time since I explored the research for Spina Bifida, so it was a good prompt to pause and take a look on PubMed to see what research I could find.    

The incidence of babies born with Spina Bifida has decreased since the link to maternal folate intake was observed, however small number of babies continue to be born each year with Spina Bifida.  For many of us, older children and adults with Spina Bifida form part of our caseload, where we regularly see the diversity of presentations and abilities within this group.   

For those who are less familiar with Spina Bifida, Spina Bifida is a type of neural tube defect that occurs when a baby’s neural tube fails to develop or close properly – the literal meaning for Spina Bifida is split spine’. Typically occurring within the first 28 days of pregnancy (while the neural tube is forming), Spina Bifida often occurs before a woman knows she is pregnant.  The cause of this neural tube defect is unknown; however it is believed to be a complex mix of both genetic and environmental factors acting together.  

There are three types of Spina Bifida 

  • Spina Bifida Occulta  this form usually does not cause any impairment and does not have any visible signs as the spinal cord and nerves are unaffected.  It is typically discovered as an incidental finding on an X-Ray that is done for other reasons.  

  • Meningocele – this causes part of the spinal cord to come through the spine like a sac that is pushed out. Nerve fluid is in the sac, and there is usually no nerve damage. Individuals with this condition may have minor disabilities. 

  • Myelomeningocele (also called Spina Bifida Cystica) - this is the most severe form of Spina Bifida. This happens when parts of the spinal cord and nerves come through the open part of the spine. It causes nerve damage and other disabilities.  

(Source https://www.spinabifidaassociation.org/what-is-spina-bifida-2/)  

The Spina Bifida Association of America offers an impressive number of resources for families, clinicians and educators, and they appear to be linked to the publication of a number of care guidelines for people with Spina Bifida.  One recently published guideline relates to skin integrity guidelines over childhood and into adulthood (Beierwaltes et al, 2020), while another that caught my interest was the Neuropsychological Care Guidelines (Queally et al, 2020). 

Prior to looking at the neuropsychological care guidelines, it is worth noting that Spina Bifida Myelomeningocele (SBM) is also associated with a collection of changes in the brain.  Looking at an article published by Juranek and Salman (2010), it is acknowledged that the failure in neural tube closure at the level of the spine also results in altered brain development, in both its structure and how it functions.  Studies have documented a remarkable degree of variation among individuals with SBM in terms of the size, shape, and appearance of the cerebellum, corpus callosum, and cerebral cortex. Similarly, a wide range of cognitive strengths and relative weaknesses among individuals with SBM are also documented in the published literature. 

Common structural characteristics associated with SBM include (Juranek and Salman 2010) 

  • Changes in the development of the skull 

  • Chiari II malformation – complex changes that involve the midbrain and hindbrain (i.e. pons, medulla, and the cerebellum) and cervical spinal cord, it is also associated with a significantly smaller posterior fossa with its contents crowded and distorted in appearance  

  • Hydrocephalus 

  • Corpus callosum hypoplasia and dysgenesis  

(For an overview of the anatomy of the brain, please see https://www.hopkinsmedicine.org/health/conditions-and-diseases/anatomy-of-the-brain) 

Coming back to the neuropsychological care guidelines (Quelly et al 2020), it is noted that individuals with Spina Bifida show a pattern of strengths and weakness across different areas, with a particular pattern seen with individuals who are born with a myelomeningocele, as comparted to individuals born with other types of Spina Bifida, who tend to have a more typical cognitive development.  

Individuals with Spina Bifida Myelomeningocele (SBM) tend to show strengths in learning skills that rely on rule-based processing (e.g., math fact retrieval, word reading) but have some difficulties when learning how to integrate this information (e.g., math problem-solving, reading comprehension).  In language and reading areas, vocabulary, grammar, and word recognition are strengths, however, children with SBM experience challenges in listening and reading comprehension, with the cause of these challenges being linked to changes in the corpus callosum.   In mathematics, children with SBM can learn math facts; however, complex procedures that require multiple steps and algorithms are an area of challenge. They often experience difficulties with estimating quantities and have impaired math problem-solving skills. 

Many children with SBM also meet criteria for Attention Deficit/Hyperactivity Disorder, however their presentation differs to children with developmental forms of ADHD related to self-regulation.  The attention profile of children with SBM is characterized by under-arousal and are related to disruptions in midbrain and posterior cortexwith evidence of this present from infancy.  

There remains a large amount of variability in the neuropsychological outcomes of people with SBM, these can be attributed to variability in the changes in the brain, as well as variables that impact on all individuals, such as socio-economic status and education.   Health related challenges, such as more severe hydrocephalus or repeated shunt malfunctions can also influence outcomes, and individuals with higher lesion levels have more severe neuroanatomic brain malformations and higher rates of intellectual disability. 

The neuropsychology guidelines offer evidence based or best practice recommendations for children by age group, highlighting different areas of cognitive development that needs to be considered.  The ultimate goal for these guidelines is to maximise a persons performance in education and in turn their ability to participate in both employment and independently in the wider community.  

Another article that caught my attention was the The Management of Myelomeningocele Study by Farmer et al (2018).  This article followed on from previously published research on this randomised control trial.  The Management of Myelomeningocele Study (MOMS) was a multi-centre study comparing outcomes of an antenatal repair to the traditional postnatal repair, with 183 people recruited for the study, randomised into two groups.  Eligible patients were women carrying a foetus diagnosed with Spina Bifida Myelomeningocele between 19-25 weeks gestation.   Initial outcomes of the study demonstrated that prenatal repair of the myelomeningocele reduced the need for cerebrospinal fluid shunting and improved neurologic function.  A urologic subgroup study identified that prenatal surgery did not reduce the need for clean intermittent catherization, however it did reduce the incidence of secondary complications of the bladder.  The prenatal surgery group featured less females and the level of the lesion tended to be higher, however when followed up at 30 months of age, children in this group were more likely to have a level of function better than expected according to the anatomical level of the lesion.  The prenatal group were also more likely to walk (44.8% vs 23.9%) and have better gross motor skills.    

The research team explored the prenatal surgery group further, to help identify which children are likely to benefit most from the prenatal surgery, given prenatal surgery does not come without its risks.  Looking at the 39 children who later gained independent walking, these children all demonstrated spontaneous hip movement (with 38 also demonstrating knee movement) in their antenatal ultrasound.  However only approximately half of those shown to have hip or knee movement on ultrasound could later walk.  For the nine children who did not demonstrate any hip movement on ultrasound, none of these children could walk independently at 30 months.  Other factors that correlated with the ability to walk included the level of the lesion and the absence of a sac over the lesion, however the need for a shunt was not associated with motor function.  The 30 month review also assessed for cognitive development, however no differences in cognitive development were seen between the groups.  

For those who are keen to learn more about Spina Bifida, the American Spina Bifida awareness website is well worth a visit, other resources include orthopaedic management, aging with Spina Bifida and general wellbeing, not to mention easy to read resources for parents.  

https://www.spinabifidaassociation.org/ - American Spina Bifida Association 

Beierwaltes, P., Munoz, S. & Wilhelmy, J.  (2020) Integument: Guidelines for the care of people with spina bifida.  Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach. 13: 543-548 DOI 10.3233/PRM-200723 

Farmer, D.L., Thom, E.A., Brock, J.W., Burrows, P.K., Johnson, M.P., et al (2018) The Management of Myelomeningocele Study: full cohort 30-month pediatric outcomes.  Americal Journal of Obstetrics & Gynecology.  https://doi.org/10.1016/j.ajog.2017.12.001 

Juranek, J. & Salman, M.S. (2010) Anomalous development of brain structure and function in spina bifida myelomeningocele.  Dev Disabil Res Rev. 16(10) 23-30. doi:10.1002/ddrr.88. 

Quelly, Q.T., Barnes, M/A., Castillo, H., Castillo, J., Fletcher, J.M. (2020) Neuropsychological care guidelines for people with spina bifida.  Journal of Pediaric Rehabilitation Medicine: An Interdisclipinary Approach.  13: 663-673 DOI 10.3233/PRM-200761


 

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. 


As technology has evolved, so too has the technology, materials and electronics that go into powered mobility base designs.  Most complex rehabilitation bases are now modular in nature, meaning multiple components can be combined to provide a solution that is unique to an individual. Some of these components are essential to the build of the chair while others are required to provide the optimal functional outcome required for the end user.

Often we only become aware of what components are required to build a chair when we receive the quote – where quotes can differ from country to country, state to state and with different suppliers. It  can be quite overwhelming when the components are itemised within a quote, especially when we are not intimately familiar with power wheelchair bases and we need to be able to complete a report to the funder to justify the cost of the solution.

How do we know what information in the quote needs to be justified in our funding report?  The foundation to any good funding report is sound and well-articulated clinical reasoning. Our clinical reasoning process should help us identify what features will be required or needed to meet the user’s identified goals. But how do we consistently achieve this? By following a process and articulating that process clearly we can demonstrate sound clinical justification.

For the purposes of this blog we will look at the dictionary definition of feature and specification and how we can use these terms to assist with our report writing.

When we look to dictionary meanings, we see a feature described as a distinctive part of something, whereas the definition of a specification is more about the recipe or the plan to build. If we consider these definitions, we can also consider features within powerbases as the additional functions it has above and beyond a standard driving base unit. The specifications then relate to how this feature is designed or operated.


 


Let’s take the example of a powered seat height function. The AT feature would be that you can adjust the seat-to-floor height of the base. This feature is available on a range of chairs from multiple manufacturers; however, seat elevators are designed and operate in different ways. This includes the mechanical differences; there are differences between a scissor lift, a Colum lift and Permobil’s AP unit, height ranges and travel. Once you have identified the functional requirement of a feature then you can consider the specifications and how this may impact on the functional outcome for a specific end user.

Let’s consider a client we have assessed for a powered mobility base. What are the clinical decisions that need to be made?

  1. What configuration will best meet this user’s goals? What environments and terrain do they normally traverse? What is the access like? What kind of turning spaces are required to access all areas of the home?  What experience has the user had with mobility bases? What are the barriers currently impacting on mobility? These are some of the considerations when determining the drive base. Different drive configurations will manoeuvre and drive differently in different environments. We could see the type of drive configuration as a feature of the AT, where the wheel is placed exactly, and how it attaches to the chassis would be more of a specification specific to the brand manufacturer. These specifications may come into consideration when you are comparing how a base with similar features differs.Will the user require or need power seat functions to assist them in meeting mobility and/or functional goals? Power seat functions provide increased function outcomes and indeed could be seen as beneficial to all users. However when we are seeking funding for these features we need to consider them in terms of functional outcomes. We need to identify what activities and tasks are impacted by the impairment. Will being able to complete these tasks have a functional outcome? – could the task be completed without the additional seat function? As well as forming part of the clinical reasoning process, you are identifying potential justification for requesting the feature as a funded feature. I tend to think about power seat functions as features of the AT solution. How they operate, use of actuators etc are the specifications again specific to the manufacturer.


Let’s break it down:

Assessment: identify mobility and functional issues. Identify how functional Impairment impacts on task.

As part of the clinical reasoning process – initially identify features such as PSF.

Once you identify the features required you can consider the potential solutions and specifications to compare.

When completing your report it is worth noting which components are essential to the build of the chair, and which components are additional and are required for the person to achieve their identified goals. For example:

While talking to some therapists recently, I have noticed an increase in the justification for functional outcomes for things that could be seen as more of a specification, for example a standard joystick. 
Looking at the big picture, the feature we are looking at here is the drive control method, or how the person will drive the chair. When considering drive control options, there are multiple options that are associated with different costs, with a joystick being the ‘standard’ and lowest cost option. Hence it does not typically require any justification, unlike alternative drive controls which are higher cost hence require additional justification in your report.

Something that is integral to the base such as the joystick for example. Whilst clearly the joystick is an AT feature of a powered wheelchair it is also integral to have a standard joystick as a minimum to operate a powered wheelchair – as such whilst it is important to have considered the input method and can be valuable to comment on, its more important to discuss any alternative controls as these are additional features that are a requirement for that specific users ability to operate their chair. Another example, the control box for seat functions – do we need to explain this or do we need to make a clear case between need and the actual seat functions recommended.


To ensure these functions are essential requirements we need to clearly articulate how these features improve functional outcomes. These examples sometimes come about because of the description or wording on the quote or how the quote has been itemised and at other times because we are not sure what a specific item is. The AT features or additional or non standard features that the clinical justification needs to focus on is the clinical outcomes and necessity for the user. If you’re not sure of a specific item on a quote reach out to your local dealer or Permobil Rep or us here at the Clinical team.


Although it can appear overwhelming, you local product specialists are there to talk you through and assist you to compare the various powered mobility bases available. They understand the specifications and how they relate to the differences in bases. We also have a range of clinical educational opportunities to assist therapists in building their knowledge and clinical prescription skills. You can reach out to us at any time for any support or to chat through a scenario. For those therapists with more experience prescribing bases make sure you keep up to date with the latest technologies and advancements by staying in touch with your local supplier and seeking experiences to try out and compare how AT features differ based on specifications.

Its important to remember we are all at different levels of experience and have different levels of clinical reasoning. If your feeling a little uncertain around the process or powered mobility base prescription reach out to your local educator 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.

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.