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It All Begins with the Mat Assessment

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We spoke last week about 24-hour positioning and its importance for the client, but how do we know what products to use and how to position our client? This all begins with the mat assessment. The mat assessment is where we will be able to determine any postural asymmetries, decreased range of motion, contractures, muscle tone, and so much more for the client’s seated position. Although the mat assessment typically will be utilised for the seated posture in the wheelchair, it can be beneficial for any surface the client may be on throughout their day. If you have never completed a mat assessment or are still new to the process – the most important piece of advice is to remember to breathe, get hands-on, and write down what you feel/see. Mat assessments can be scary when you first start, but ultimately it will provide you with the information you need to provide the best care to your client. So where do you begin?

Begin first by trying to find a hard surface for your client. Not every therapist will have access to a mat and that’s okay. It is important to try to find a firm surface so that you’re not getting false information back. The client’s safety and well-being are most important, so be sure to make sure your client is safe on the surface you choose.

 

 

You want to assess the client in both supine and sitting. The assessment in supine will allow you to not only assess the client without the effect of gravity, but it will also allow you to safely assess the client’s range of motion. I have included a few great resources below on mat assessments and a few helpful forms you can utilise. It is important to either have a form to fill out, or to write down what you see and feel as you go along. The last thing you want to do is finish the mat assessment and then forget what you have just done! Once the supine examination is over then you can complete the sitting examination.

For the sitting examination, be sure your client is safe at all times! You may have to provide support by sitting behind your client or having a second person for safety. The seated examination will give you feedback on the client’s position with gravity, position of their head and trunk, their balance, and so much more. Here is where you can really get hands on and determine how much support the client will need in their wheelchair. I like to use my hands as laterals, chest straps, or as whatever positioning items I am thinking of to mimic their effects. Remember to give your client proper foot support during the sitting examination.

 

 

If I can give one piece of advice when learning mat assessments is to PRACTICE! Practice on your family and friends. Practice on other therapists. Feel comfortable with your process before you try to just jump two feet into a complicated mat assessment. The best way we can learn is through practice. Take a look at these great resources below and as always feel free to email/call with any clinical questions! I am here to help you.

Rachel

 

Resources:

Spinal Seating Modules
https://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating/module-3

Mat Assessment Guide
https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0005/312791/RD5.2_Seating_MAT_Assessment_Guide.pdf

Permobil Seating and Positioning Guide
http://hub.permobil.com/wheelchair-seating-and-positioning-guide

24 Hour Positioning:

Should I be thinking about this for my client?

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Before we can answer this question, we first need to make sure we understand what 24-hour positioning is. I briefly discussed this last week as 24-hour positioning will be one of the main 3 themes you hear about this year throughout our weekly blog posts.

Let’s think about a circle, clock, or a pie. Now, let’s break this clock up into 24 hours instead of the typical 12. Think about how much time you spent on each surface you sat, stood, or laid down on. How many hours were you sitting at your desk? How many hours were you laying in your bed over the last 24 hours?

Now let’s think about this clock for your client. How many hours does your client spend on the bed each day? What about their wheelchair or their favourite sofa? Maybe their clock would like this this:

 

 

What does this mean and why does it matter to us? It is important for us as a therapist and every team member involved in the procurement of complex rehab technology to be involved in the appropriate selection of this equipment.

Many if not most of our clients have decreased or limited mobility and/or sensation. This means that they are at a risk of skin breakdown. It also means that they may not be able to maintain a neutral posture, and without proper positioning the client may end up with postural asymmetries. These asymmetries such as scoliosis and pelvic obliquities can put the client at further risk of skin breakdown but can also affect their functional independence. Let’s think about an example. Imagine that you never had a back to your chair that you sat in at work. Would you sit up straight throughout your day or do you slowly allow your spine to curve and end up with some thoracic kyphosis?

 

 

For me, I constantly find myself “slouching” or going into a thoracic kyphosis throughout my day. Now, what happens if I didn’t have strong enough muscles in my trunk to fix my posture? I would be stuck in that “slouching” position for hours of my day and eventually over time my muscles would get tighter and that “slouching” position would be my new normal position. The cycle would continue to progress until perhaps my posture was bad enough to start causing me pain and a cascade of other impairments. This is what can happen to our clients if they are not properly positioned throughout their entire 24-hour day and it is not just with sitting. We can think about how even the positioning in bed can potentially have more of an impact than the wheelchair that the client is only sitting in. What if the client is in their bed for 8-12 hours a day and only 4-5 hours a day are spent in their wheelchair? Have we thought about how they are positioned in their bed? My favourite example to think about for bed positioning is the neck and head. Many times, our clients will have 3-4 pillows under their head for comfort, but what happens to the position of their neck? Now, some of the clients may need this positioning for medical management, but if the client is safe to have less pillows, we want to keep the neck closer to neutral. I see numerous clients that have pain in their neck and forward head position limiting both their vision and functional independence, but perhaps it is not just the position in the wheelchair that is the issue. Perhaps instead it is that the client needs changes to their positioning in the bed first.

We will continue to explore the topic of 24-hour positioning, but I hope you finish this blog today with the idea that positioning on every surface matters. It is crucial for us as part of the team to consider every surface that our client is on throughout their day and how their position on that surface can impact not just their positioning, but also their well-being, participation, and independence.

Rachel

 

 

 

Happy New Year!
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Permobil is excited for 2019 and we have BIG plans this year to keep bringing you the most up to date and top information, products, and service!

In order to provide the best blogs and education for this year, we decided to return to the root of why we are all here: The end-user. To accomplish this, we chose a few topics that affect our end-users daily. We will then use these topics, or themes, throughout the blog posts this year. It is important to remember that whether we are discussing specific products, features of wheelchairs, or general concepts, that everything points back to the end-user.
 
The blogs for 2019 will primarily focus on 3 main themes: Shoulder preservation, independent access, and 24-hour positioning.

 

 

Shoulder Preservation
Shoulder Preservation is extremely important as many end-users require their upper extremities for their mobility in addition to everything that we ask of our shoulders every day. This places the shoulders at a high risk for injury. Often, we think about this only with manual wheelchair propellers, but many power wheelchair users experience shoulder pain as well due to the increased requirement for overhead activities. This year we will focus on shoulder preservation by talking about the shoulder anatomy and physiology, the products on the market to assist with shoulder preservation, and how simple changes can make a big difference when it comes to the shoulder.
 
Independent Access
Independent access can vary from talking about our community that we live in, our home and its accessibility, or the equipment that the end-user utilises. No matter what the discussion is about though, the key is that every person has the right to the same technical standards. This year we will focus on what independent access truly means, the equipment and technology that is helping to allow for this, and how we can continue to design and develop ways to further allow independent access to everyone at the same standard that many of us live in our everyday lives.
 
24-Hour Positioning
Think about a clock and how you spend your time. If we think of this clock as 24 hours and separate it into sections of time for our clients, how much of this time is spent on different surfaces? Is the end-user always in their wheelchair? Or, are they on several different surfaces throughout those 24 hours? Many times, the wheelchair is perfectly fit to the end-user and provides the end-user with positioning to maintain a proper neutral posture. The problem is that this is not the only surface the end-user is sitting on throughout their day. What about the child that is using a power wheelchair for mobility in school and comes home to sit on the sofa. The child just spent 7 hours being perfectly positioned and now is slouched on the sofa for the next 3 hours. Does this negate the past 7 hours of positioning? We will explore this year how we can take that positioning, and skin protection, across 24 hours to ensure the best possible outcome for the end-user.
 
I hope that you will find these blogs useful and meaningful. 
 
Rachel
 

VSC |  An App Designed for You

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Can you imagine a world where the end-user would know the exact angles of their power wheelchair?

 

Where they would no longer have to guess if they were positioned correctly for pressure management? Or where they could easily go to an angle of tilt to access smaller entryways without the question of, “Did I tilt far enough back?”. All of this is now possible with Virtual Seating Coach by Permobil. You can now download a free app and pair with your power wheelchair to view your seat angles in real time.

To further discuss Virtual Seating Coach, this week we are going to hear from a guest blogger Stacey Mullis. Stacey is the director of Clinical Marketing for Permobil in the US and has over 20 years of experience as an occupational therapist.

Let’s face it: it can be overwhelming to learn every function that a power wheelchair has, every aspect of medical management, and manage daily ADL routines. Certainly, it’s helpful to be trained by a seating therapist on how often to change positions and the specific angles of changes. But to say that it becomes a habit right away? Not going to happen!

The University of Pittsburgh conducted a study on two groups of end users. Both groups received training on the frequency of position change as well as the angles/positions to go into. One of the groups was then provided with the Virtual Seating Coach app in addition to that training, and their use of power seat functions increased by 40%! It’s all about building habits, and the more automatic a behaviour becomes the less overwhelming it is.

How does VSC work?

Your seating therapist should have already done an extensive, thorough evaluation to get you into your current seating system. As a  result, he or she will know your clinical needs based on your medical and physical condition, your prognosis, and risk factors, and he or she can individualise a plan just for you! Although there are clinical practice guidelines, your therapist may find that you, for example, will benefit from four small changes in tilt/recline in an hour, then one longer more aggressive tilt and recline the next hour. In this case they will go into their clinic’s portal and assign you a specific regimen accessible through your app. It will literally coach and cue you on the following:

• Frequency of each tilt, recline, and power legs adjustment
• How long to stay in a position before coming out of it
• The angles you should be reaching in tilt, recline, and power legs with indicators that let you know you’ve reached them

 

Your therapist can set daily goals, and you can start noticing the benefit of this healthy habit of movement. The VSC app will automatically capture data as you utilise the power seat functions daily. This data will allow you and your therapist to monitor progress toward your repositioning goals.


The Virtual Seating Coach is one way you can be empowered to manage your care and decrease the health risks of immobility.

 

 

 

Did you know your Power Wheelchair could have Bluetooth?

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We live in a connected world. A world full of phones, tablets, and computers. Most of us use technology every single day. For many of us, it is difficult to even be without technology for a few hours. We are constantly looking at our phones whether it is to see the time, make a call/text, or use one of the thousands of apps available to us. For individuals with impaired hand/upper extremity weakness, being able to fully use a phone or computer is not always possible.
 
For many years now, most power wheelchair manufacturers have integrated Bluetooth into their chairs. What does this mean? It means that the wheelchair user can have their phone, tablet or computer connected to their wheelchair. The power wheelchair can control their phone, tablet, or computer with their driving device. Bluetooth can be utilised with any driver control: joystick, head array, chin drive, etc…

The type of connection will depend on the type of device. For iPhones this connection will be through switches where a blue box will appear on the phone allowing for selection of items. For Android and Microsoft phones and computers this connection will be through mouse emulation where a mouse pointer will appear on the screen.

The video below is an example of a Bluetooth iPhone connection with switches. A big Thank You to Todd Stabelfeldt for posting this great video.
 
 
 
The best part about Bluetooth on the wheelchair? As a therapist you can set this up on your client’s wheelchair. The set up will vary slightly based on each manufacturer and the age of the wheelchair and also the type of joystick or speciality input device is being used.
 
Included below are two quick start guides for getting started with Bluetooth on both iDevices and Android/computers on Permobil power wheelchairs with the Permobil Joystick Module.
 
 
 
 
 

Independent Repositioning Mode:  Getting the Most Out of Your Power Seat Functions

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We have been discussing the importance of power seat functions for the past couple blogs and what those power seat functions can do for the user. Often because of the limited mobility of the individual utilising the power wheelchair, power seat functions are used for pressure management. Pressure management or shifting weight off the user’s bottom is crucial to help to decrease the risk of skin breakdown. There are numerous research studies that discuss which combination of power seat functions are best for pressure management. The research shows that superior pressure relief may be achieved by utilising both posterior tilt and recline. Based on research by David Kreutz in 1997, the individual is recommended to initially move to a fully tilted position to stabilise the pelvis, and then follow with activation of the recline system so as to minimise loss of postural stability. Then reverse this order for coming back up to a driving or functional position: Recline and then tilt. This order is important because if the user starts for example with power recline they may lose their stable seated position or increase shearing to their sacrum. Commonly, users will have access to power posterior tilt, power recline, and power elevating legrests. In this case, the user should complete the following sequence for pressure management: posterior tilt, elevating legrests, recline. Then, reversing this order for coming back out to an upright driving position. When the user is fully tilted and reclined, this position is also helpful to reposition the user. Many users may be able to unweight their pelvis and shift their own hips in this unweighted position.

So, what is the challenge with utilising the sequence of posterior tilt, elevating legrests, and recline to maintain postural stability during pressure management? This sequence can be difficult for the user to remember, or maybe the user does not know the difference between recline and posterior tilt if they were not educated by their therapist or other seating specialist. This can create a fear for therapists and many will prescribe just posterior tilt in order to prevent the potentially negative effects of the 3 power seat functions when not used in the right sequence. Or, maybe the user is given all 3 power seat functions, but instructed to only use tilt for their pressure management. This is where it is important for manufacturers to see this limitation and develop a solution.

This solution for Permobil is called Independent Repositioning Mode or IRM. IRM comes standard on every F series, M3 and M5 power wheelchair.  This mode can be turned on to where the user can press a button on the controller, hit a switch, or use the actual joystick to enter the independent repositioning mode. Because the chair has smart actuators, when the switch for example is hit, the chair will take the client into a pre-set or therapist set amount of tilt, legrest elevation, and recline in the proper sequence one after the other. The user only has to know in this case to hit one button.  Users no longer have to worry about going all the way into posterior tilt before elevating their legs and then reclining. This feature is designed to take the stress and difficulty away from the user, but also empower the user to be able to be independent with their own pressure management.  Independent repositioning mode can also help with exactly what it says – repositioning. For some users, they are able to hit a button and go into this position so that they can independently repositioning their seated posture.  While the user can be set up for the standard IRM position, the therapist can also choose the final position of IRM so that this feature can be utilised for every users’ needs.

Click here for more information on power chairs.

Rachel 

 

References:

Kreutz, D. 1997. Power tilt, recline or both. Team Rehab Report, March: 29–32.

 

Power Seat Functions  |  Elevation

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Today we will look at the power seat function for elevation.  When we talk about elevation, we are referring to the raising up of the seat pan. You may also hear elevation referred to as seat elevate, or lift. Elevation can be beneficial to the user for functional, psycho-social, and physical benefits.

Let’s start with the functional benefits. The first benefit is the improvement of or independence with transfers.  Many people need to complete lateral transfers, where they slide across from their wheelchair to another surface such as the bed, toilet, or car. The difficulty with lateral transfers occurs when the user has to go from a lower surface to a higher surface. With seat elevate, most transfers out of the wheelchair can now be level or with a slight decline. The seat elevate can also be helpful with sit to stand transfers.

Another great function benefit of elevation is the improvement of the user’s vertical reach.  Often with sitting in a wheelchair, activities or tasks will become overhead.  This means that the user has to be able to reach overhead to complete this task or activity. Seat elevation may allow the user to increase their independence by completing overhead activities, and this can also lead to additional physical benefits. Overhead reaching could increase the user’s risk of shoulder impingement or perhaps the user does not have the strength in their arms or trunk to complete this task or activity, and with seat elevate this will no longer be a problem.  It’s not just about the shoulder.  There is also a large impact on the neck, or cervical spine, with constantly performing overhead activities or looking up throughout the users’ day. Seat elevation can reduce the potential problems of overhead reaching.

 

Finally, let’s touch on the psycho-social benefits. In a previous blog, I discussed this topic of being able to come to eye level with your peers. This seat elevation allows the user to come to eye level with their peers, promoting the user to be part of the conversation. Seat elevation gives the user the power to choose at what height they want to be.

There are of course are a few limitations even when the user is able to elevate.  Many times, I hear people talk about how with seat elevate they will be able to reach into all of the cabinets in their kitchen.  Now, this could be true, but for many users they can now get up to open the cabinet, and reach the first few items, but they will have difficulty reach all the way into the cabinet.  This is because the user is typically seated back and would have to lean forward in order to reach further into the cabinet. This is one example, but we can see that seat elevate while very beneficial for independence with some functional activities may not provide the solution for all tasks or activities. Last week we briefly discussed ActiveReach™ and its benefits with vertical reach. For those clients that are looking to get that further reach, have better access to their sink and kitchen, and to even further enhance their participation through active posture, ActiveReach™ that includes both elevation and anterior tilt might be the right choice.

Remember, not everyone will need seat elevate, but it is important to assess each individual and determine if the function is appropriate. 

 

 

Power Seat Functions: We want to hear from you!

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Often when we think about power wheelchairs and their power seat functions, we think of tilt first. Tilt is a great power seat function, but depending on the power wheelchair and the manufacturer, power wheelchairs can have other power seat functions. These power seat functions may include: elevating leg rest, recline, standing, or the Permobil ActiveReachTM.  When we think about power seat functions and their use we might think about how these power seat functions allow the end user to be independent with their pressure management. We might think of power seat functions for health benefits like to assist with decreasing lower extremity swelling, but what about for functional independence and psychosocial benefits? While it is very important to remember that these power seat functions can help assist with pressure management and other health benefits, for the next couple weeks I want to focus on all of the power seat functions and how these functions help benefit end-users in their everyday life.
 
If you or anyone you know is using a Permobil power wheelchair and uses their power seat functions to increase their independence, get more involved in the community, return to work/school, or maybe just for fun we want to hear from you! Please email Rachel.Fabiniak@permobil.com with your story and photo, so that we can include you in our next blog!
 
As a therapist it can be difficult to determine which power seat functions would be reasonable and necessary for my client to have on their power wheelchair.  It is important for us to consider the goals of the client and to determine if a power seat function could help to achieve this goal.  A great example of this is with ActiveReachTM.  Perhaps a client would like to increase their independence in their morning ADLs, activities of daily living.  Many times they might not be able to fully access their sink because the sink is too high.  Or maybe they can use elevate on their wheelchair to raise up closer to the sink, but they are sitting too far back in their chair to fully use the sink.  With ActiveReachTM, they are able to not only elevate, but to tilt forward to allow for full access of their sink.  Clients who couldn’t reach to brush their teeth in the sink before might be able to complete this activity independently because of this power seat function. This is just one example of how a power seat function can assist with independence.
 
Over the next couple weeks, I look forward to discussing how our users utilise their power seat functions.
 
Rachel
 

Power Wheelchair Suspension: What you need to know and look for

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Over the past 3 weeks we have talked about drive wheel configuration and some tips on how to decide which option is right for you. This week we are going to discuss power wheelchair suspension. The suspension can vary from chair to chair even within each manufacturer, but there are some key points that we should discuss.


Most power wheelchairs on the market are going to use compression springs for their suspension. There are two types of compression spring that are typically used: Linear and Non-linear.


Non-linear springs as seen in the photo below allow for changes in compressive load at different points of the range. What this means is that you can have the looser spring coils at the beginning phase to help with climbing over obstacles. The trade-off will be that you will lose some of the overall stability of the chair when not climbing. Many manufacturers will use one non-linear spring as their suspension.


Linear springs on the other hand allow for consistent stability throughout the compression range. For Permobil, these springs are also adjustable. The factory will set the suspension spring resistance based on the weight of the user and then the supplier or manufacturer representative will have the ability to further adjust depending on the needs of the user. With the Permobil M and F series, the suspension will be composed of multiple linear springs to achieve optimal traction and suspension.


 

Why does this matter? The shape and the coil distance have an impact on how a spring works and effects the user. The better the suspension, the greater the decreased forces on the end-user. This could lead to increased seating tolerance, pain management, spasticity management, and decreases the risk for loss of balance or position in the wheelchair. One of the biggest points that I think about is driving over any uneven terrain whether it is just a sidewalk or grass at a park. It is important that as the chair goes over each bump that this bump is not felt by the user or limited as much as possible. If each bump is transmitted up to the user, then the user will likely not maintain their seated position. They will also feel all this vibration. According to one study by Wolf and colleagues in 2007, this vibration can lead to many impairments including fatigue and pain.

 

 

 

The final thought that I believe is one of the most crucial points to make is that the suspension on the wheelchair should always be there for you or your client. We know how important suspension is and the negative impact that not having this suspension could be to our clients. Therefore, we need to make sure that the wheelchair will maintain its suspension in any position and over all surfaces. No matter what position the user takes the Permobil power wheelchair to, such as elevate, posterior tilt, active reach, or standing, the suspension remains the same. If you want to drive your wheelchair in elevate, active reach, standing, or other positions, you want to be sure that your suspension will continue to support you in those positions and not lock out.


It is important to know that each manufacturer will have different suspension set up on their chairs. As a client, therapist, or carer make sure you ask about the suspension to determine which option is best for you.

Rachel

 

 

Part 2 Power Wheelchairs: 

Where is my Drive Wheel and Why Does it Matter?

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

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

MID-WHEEL DRIVE

The mid-wheel drive power wheelchair is the most recent technology developed for power wheelchair bases. It attempts to combine the positive aspects of front-wheel and rear-wheel drive into a hybrid product. Mid-wheel drive has many benefits.  The most well-known benefits being the small turning radius and intuitive driving.  The mid-wheel drive power wheelchair has the smallest 360  ĚŠ turning radius which can improve manoeuvrability for many individuals in their home or smaller spaces.  The intuitive driving benefit is due to the placement of the drive wheel. Typically, in the mid-wheel drive, the client will be sitting directly over the drive wheel, which is where the chair will turn/rotate from.  This axis of rotation being directly under the individual is what makes the driving intuitive or often people will say “easier to learn”.  It is important to remember that in some cases the mid-wheel drive may not line up directly below the client and therefore may lose some of that intuitive driving.  The final benefit to discuss for mid-wheel drive is the stability.  Because a mid-wheel drive wheelchair has 6 wheels on the ground, this chair will offer superior stability. This can be the case whether ascending, going up, or descending, going down, ramps or inclines.

While there are many benefits for mid-wheel drive power wheelchairs, there are a couple considerations when deciding if mid-wheel drive is right for you or your client.  In being a superior option for stability, the 6 wheels on the ground also means that more energy from the ground is transferred to the client. Imagine going over a bump, because there are 6 wheels you could feel that bump 3 times versus the 2 of the front-wheel drive.  This could potentially limit the ride comfort for the individual in the chair.  Luckily, depending on each manufacturer, we have suspension to help decrease the impact of having 6 wheels on the ground.  I LOVE talking about suspension and we will have a blog post coming soon to talk all about suspension in power wheelchairs and the importance of the suspension.  The other comment I hear about mid-wheel drive power wheelchairs is the potential for “high centring”.  This term is used to describe when the centre drive wheels lose traction and may not be able to move in certain situations. This is particularly a risk with uneven terrain and was previously the biggest disadvantage of the mid-wheel drive power wheelchair. However, depending on your manufacturer, newer technologies and suspension can compensate and have greatly decreased the risk of this occurring.

The mid-wheel drive power wheelchair is the most popular drive wheel configuration and for good reason.  As technology continues to progress, the mid-wheel drive continues to have greater benefits with less limitations.

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

Rachel