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Travel – Essential AT for Two Different Locations

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In 2019 I was fortunate enough to travel to two very different destinations, Portugal and Thailand. Despite the differences between the two destinations, there are a few pieces of assistive technology that helped me make the most of these two trips.

To begin with, Portugal. Portugal has been on our list of places to go for many years, and in 2019 my wife and I decided to make it happen. As a wheelchair user who has done considerable travel over the years for both business and leisure my strong preference is to pick a place and spend time there rather than spending a night or two at several locations. This saves me the hassle of searching for accessible rooms, packing and unpacking, and hours in transit.

It has the added advantage of letting me get to know one place well, to find places that are often overlooked by tourist guides, to find the best food and cafes, to meet some local people and shopkeepers and to have a better taste of what life is like. In Portugal we decided we would spend our time in Porto.

 

 

For accommodation I used AirBnB. The accessibility filters now in the AirBnB website have worked well for me. We ended up in one-bedroom apartment right in the heart of Porto, equipped with a kitchen, good living room space and a bathroom set up that worked for me. This option was cheaper than the hotels with good accessibility and allowed us to buy the local cheeses, meats, olives, wines and other produce without having to eat out all the time.

 

 

Porto is an ancient city, built around the Douro River. This means there are a lot of steep hills, cobblestones, steps into shops, and at times narrow crowded sidewalk. Not ideal for wheelchairs! But to compensate for this it is a beautiful city, with magnificent views, architecture, history and very friendly locals. In addition, there is some excellent infrastructure such as the funicular, cable cars, accessible buses and accessible paths along the river and on the famous Dom Luís 1 Bridge. We also did a half day river cruise which was spectacular and then caught the train back to Porto (the train stations had portable ramps to get me into and out of the carriage).

 

  

 

In terms of getting around, we explored a lot of the city by wheeling/walking. We used the buses a few times, but mostly we just wheeled/walked to different areas. I find one of the attractions of old cities like this is to just wheel through the lanes and alleyways, get a feel for the history and be surprised by the small shops and their produce.

 

 

 

I will let the pictures and videos do much of the talking regards the beauty of Porto. In regard to equipment, the two vital pieces of equipment were the SmartDrive and the FreeWheel. These two products work so well together, the FreeWheel for the cobblestones and going down steep hills, the SmartDrive for getting up the steep hills. Having travelled through Europe without the FreeWheel, the difference it makes on cobblestones is truly liberating! Having the SmartDrive allowed my wife and I to explore much more of the city than we could of without it.

 

 

 

Moving onto Thailand, this has been one of my favourite destinations for many years. I have found it challenging (I kind of like to be challenged in my travels) but really rewarding. This trip I focused on two areas, Chiang Rai which is a mountainous province in the North West of Thailand famous for the Golden Triangle, and Prachuap Khiri Khan province in South West Thailand. In Chiang Rai I hired a car from the airport, and for the Prachuap Khiri Khan I hired car and drove from Bangkok (about a 4 hour drive). I travel with portable hand controls which can be fitted to an automatic hire car.

 

 

The Chiang Rai area is incredibly beautiful, and I really enjoyed exploring the mountains and the area known as the Golden Triangle. The history of this area is rich and fascinating, and the food is to die for. The influence of different tribal groups, the surrounding countries and the West all make it an intense cultural experience. While not as filled with tourists as the Thai islands and Chiang Mai, there is still reasonable infrastructure.

 

 

The other area I went to, the Prachuap Khiri Khan province, is a beautiful province that is largely unspoilt. The place I stayed in is very close to the biggest national park in Thailand (more jungle than park). It is only about 50 minutes from Hua Hin, a nice seaside village on the coast which is a popular tourist destination. However, where I stayed is far from the hustle and bustle of tourists. It is a new resort, on a river that had otters in it! All the other guests were Thai, I was the only foreigner staying there. Driving there I passed through areas that warned drivers to beware of wild elephants on the road, the bird life is incredible, and the scenery must be seen to be believed.

 

 

Once again, the SmartDrive and FreeWheel played a critical part in my being able to explore these areas. In the mountains of Chiang Rai, the SmartDrive took me to places I could not have got to without it. The FreeWheel allowed me to explore dirt tracks and off-road areas, as well as cross a suspension bridge that had big gaps in the planks.

If you’re interested in any more details regarding these two trips, please don’t hesitate to contact me. I hope wherever your travels take you in 2020 you have a great time!

 

Malcolm Turnbull

Senior Advisor and Ambassador

Mal - 40 years a para’ 

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40 years ago, in the late hours of January 6th, 1980, I was a passenger in a vehicle that went over a 20-metre cliff. After a long wait to be found and rescued, I arrived at Coffs Harbour Hospital with a broken rib, a punctured lung and a deep knowing that something was significantly wrong. Not long after receiving my x-rays the local doctor came with the news that my spine was severed at T5 level, complete, and that I would never walk again. It was a short conversation, in retrospect a blunt statement of fact that I remain grateful for. The full impact of this life changing event would unfold over the years and continues to unfold as I enter into my 60th year. 40 years, two thirds of my life, as a wheelchair user.

There is much I could write about my experiences in Prince Henry Hospital and the following years, enough to fill a book. But today I want to reflect on some of the changes that have happened over the past 40 years. 

There have been obvious changes in the quality and range of Assistive Technology available. My first wheelchair was a chrome plated folding frame wheelchair that weighed around 24kg. It was an “off the shelf” chair, it was so big I “swam” in it. Pioneers in modern wheelchairs, the likes of Michael Callahan, Nick Morozoff, Marty Ball and Mike Dempsey (all wheelchair users) paved the way for the amazing range of manual wheelchairs available today.

The advanced technology built into powered wheelchairs that allow for even the most mobility challenged users to not only get mobile, but to be able to do so in various seating/standing positions and with maximum comfort. Improvements in seating and positioning products, pressure care cushions and support surfaces, motor vehicle modifications and control options, off road devices – power assist was not even a concept in the 1980s. 

Environment control systems were starting to appear in the late 1980’s but they cost tens of thousands of dollars and required specialised systems and installs. Now off the shelf devices from mainstream companies are doing more than could ever have been imagined. Add to that the robotics that are in their relative infancy. I find the range of Assistive Technology available today mind boggling, and it is hard to imagine what will be happening in 40 years from now!

Apart from Assistive Technology, facilities for, and attitudes towards, people with disabilities have vastly improved. In 1980 I could access three railway stations in Sydney, there were no building regulations for accessibility, accessible toilets were few and far between and I can’t remember being able to book an accessible hotel room. In my first few years as a wheelchair user, I was referred to doctors in Macquarie Street, Sydney for specialised assessments – and all of their rooms were upstairs! I had to get out of my chair and “bum” it up the stairs, towing my chair behind me.

In 1981 the United Nations General Assembly proclaimed the first International Day of People with Disability which called for a plan of action at the National, Regional and International levels, with an emphasis on equalisation of opportunities, rehabilitation and prevention of disabilities. The theme of IYDP was "Full Participation and Equality", defined as the right of persons with disabilities to take part fully in the life and development of their societies, enjoy living conditions equal to those of other citizens and have an equal share in improved conditions resulting from socio-economic development. This accelerated awareness around disability both here and internationally.

In 2000 the Paralympics were held in Sydney, which really helped push improved accessibility. There is still a lot of work to do, here in Australia and internationally (especially in underdeveloped and developing countries) but it is a huge improvement from the 1980s.  

There have also been improvements in the attitudes towards people with disabilities. I remember when I first left hospital I would go to my local pub for a beer and people would walk past and drop a $2 dollar note on my lap (yes, we had $2 notes!). People asking my companion what I would like to eat instead of asking me, pushing my chair despite my protests, the most inappropriate questions, hushed whispers of pity and amazement that a wheelchair user could drive/work etc. It was not all bleak, of course, there were lots of fantastic people – like the staff at Ultimo UTS who made major adjustments to allow me to study Mechanical Engineering. But there was a general level of ignorance around disability that has improved greatly.

Again, there is a lot more to be done. People living with disabilities in Australia have high levels of unemployment, and there is still a degree of ignorance and fear around how to interact with people who live with disabilities. However, overall the understanding about people with disability has improved hugely. This is also reflected in the language used. Largely gone are terms such as “cripple”, “handicapped”, “retarded”, “disabled”, (although the “Disabled Bathroom” still gets a run – who wants to use a bathroom that is disabled?). In a recent trip my wife and I did a stop-over in Dubai and came across a sign referring to people with disabilities as “People of Determination”. My mum always said I was a determined little so-and-so.

Another thing that has changed dramatically is funding for people with disabilities. In 1980 you were either fortunate enough to be eligible for compensation (eg. from car insurance or worker comp) or you fell into a state-based funding scheme such as Enable. I vividly remember being in Ward 1 at Prince Henry Hospital and hearing compensation lawyers advise other inpatients to avoid work before their compensation case because this would reduce their “loss of income” payout. The compensation cases would often drag out for many years, by which time many people found it extremely difficult to return to the workforce.

The implementation of iCare Lifetime Insurance in NSW, and similar no fault insurance schemes in other states, was a big step forward but it still created a two tiered approach to care – those in the iCare scheme had access to the best equipment and care available while those in the public schemes had access to basic equipment and care. The implementation of the NDIS has been a major reform and is potentially the world leader in provision of services and equipment for people with disabilities. Again, it is not perfect and the lack of uniformity across the nation is frustrating, but it is a huge step forward and at its core embraces principles of empowerment, inclusion and participation for people with disabilities.

There is so much more that can be written, and I am sure others would have lots to say about this. Disability Advocacy groups such as The Quadriplegic and Paraplegic Associations, NSW Physical Disability Council, CPAs – so many great organisations – have made and continue to make a positive impact on the lives of people with disabilities. Medical developments, from the ambulance and first responders to the fundamentals of bowel and bladder care to advanced scanning and medical procedures have made a huge impact. Research into best practise for therapists and clinicians, the expertise and professionalism of Assistive Technology suppliers, access to travel and sports – the ground-breaking Sargood on Collaroy facility – the list goes on. 

Finally, I want to acknowledge the generations of end users that have paved the way for people with disabilities – passionate and forward-thinking wheelchair users like Mark Bagshaw, Chris Sparks, Nick Morozoff, Errol Hyde, Kevin Coombes, Kurt Fearnely and many more.

 

Malcolm Turnbull
Senior Advisor and Ambassador

The Pushtracker E2 - First Impressions

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Last month saw the release of a long-awaited update to the SmartDrive, the all-new Pushtracker E2!

If you’re looking at a power assist option for the first time, or you’re an experienced user of the SmartDrive with the previous Pushtracker, you might ask “why make the switch? What makes the Pushtracker E2 a must-have?” After using the previous Pushtracker for almost 3 years, I took the E2 through its paces and my usual route to university!

The first thing you notice is that the E2 is a smart watch, using the Mobvoi TicWatch E2 as the foundation. This new hardware ups the build quality and gives the user additional functionality such as apps on Google Play Store, phone and social media notifications, weather and all the rest. Like me, if this is your first smart watch you’ll appreciate getting your phone messages straight to your wrist. As a wheelchair user I keep my phone in a bag rather than my pocket – meaning that this is a game changer!

 

 

It also looks like a device that anyone would wear, which is important for many of us. I also can’t wait to change the wristband to something more stylish. The Pushtracker E2 is compatible with most standard 22mm bands. While on the topic of aesthetics, you can choose from dozens of watch faces and customise it to show both Pushtracker and SmartDrive Battery.

The instructions were simple enough – download WearOS on your phone, turn on the Pushtracker E2, and pair the two. Sign into your Google account on the E2 and go through the prompts. It takes a short while to update all the software, during which the watch may feel slow. Once set up, head into the Play Store to find your Permobil apps.

Permobil developed two apps for users to download onto the watch – Pushtracker to keep track of your wheeling activity, and SmartDrive MX2+ - your main control to activate your SmartDrive. The apps look sleek and are much more intuitive to use on the AMOLED touch screen compared with the old Pushtracker. You’ll want to Favourite the SmartDrive app so you can quickly press the menu button and launch the app before you tap.

https://www.youtube.com/watch?v=jLEK1C_6UiA

 

How does it feel initially? If you used the old Pushtracker it’s both familiar and different. In my case it was too sensitive by default, so I fiddled with the Tap Sensitivity setting until I found the sweet spot. For me that’s 70%. Be sure to go through Tap Training in the app settings menu to become familiar with the responsiveness. In any case, the first trip out with the Pushtracker E2 was like a mini retrial. I recommend everyone to carefully get the hang of it before using it in tight places. Pretty soon I was using it just as intuitively as before.

The trek to my university is almost one, giant hill, so I can't imagine tackling it without a power chair or power assist. It's a 5 minute ride from the station and just accessing the library at the top means there's a hill from every direction.

 

 

From my experience so far, I didn’t experience any disconnection with the Bluetooth while in-use, unlike the frustrating black spots I encountered with the old Pushtracker. The new hardware sports an antenna that’s 8 times stronger than before and it definitely feels like it.

The only trouble I had was in the initial tap to go during the first day or so, getting used to the new feel of the watch. The different sensitivity also meant the speed unintentionally set too early making have to stop and start again.

Finally, and crucially, is battery life. I noticed when not in-use the battery is far more capable than the old Pushtracker. How fast the E2 drains depends on how you use its smartwatch functions. Like a phone, I noticed it can get dangerously low towards the end of the day if the display is always in use. I recommend turning off the always-on display, reducing the brightness a bit and always turning off the SmartDrive app, away from its ready-to-tap screen whenever you stop using your power assist.

 

But with so many devices I now carry with me, a powerbank is an essential item in my backpack. It will also win you some friends! Charging is very fast and the E2 comes with a USB charger to plug into a computer or power adapter. If you charge with a computer, a blue USB 3.0 port will give maximum charging rate.

If I was to find a complaint, it would be that the watch is a bit large for my skinny wrist. But I can understand the designers opted for a size that can be easier used by those with limited hand function. For a touch screen, bigger is easier.

As an active user who needs to get around town every day, the E2 feels like a natural transition. Whereas before I would wear the Pushtracker only because I had to use the SmartDrive, I now wear it because it’s just useful for everything else. Have you got your hands on the Pushtracker E2 yet? Sound off on your thoughts below!

 

Sergei

 

Continuing Professional Development (CPD) requirements for Occupational Therapy registration

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New Zealand and Australia both require Occupational therapists to complete ongoing training as part of maintaining competency as a registered therapist. Both Systems require OTs to be nationally registered and to prove ongoing competence to the board on request. This competence is measured by the training and education opportunities that the therapist has undertaken throughout the year.  Both systems have an expectation that therapists will maintain standards and stay up to date with latest technology and practice by attending ongoing education. 

 

With a wide choice of ongoing education opportunities available in relation to AT, the education team at Permobil are confident that our clinical education courses meet the updated registration standard. For Australians the CPD hours have been reduced to 20 hours as of Dec 1st, 2019. It is important for therapists registered in both countries to keep up to date with the requirements their board imposes.  Audits for previous years will still require you to meet that year`s requirements.

I recently had a conversation with a senior OT / Team leader who was asking about our education opportunities for her staff. She articulated she had previously attended “CPD trainings” that did not offer her any professional development as were not pitched at a level she felt met the course description. She reported that she was happy to send her staff to workshops with our team as she felt they provided good skills and learning opportunities for her staff. She expressed her frustration at releasing staff to find that the course she sent them on did not actually benefit their roles.

An increasing number of services are working in a billable hour’s models, with national insurance schemes in place in both NZ and AU. This can put increased pressure on income generation and taking time out for education is not always seen as a priority. However, CPD needs to be given value, partly due to it being a board requirement but mostly because it helps us grow and become better therapists by setting goals and pushing ourselves to constantly grow.

How do we make CPD work for us? Set yourself clear goals and look for training opportunities that will address your goals. Read course and workshop descriptions to see if they include skills or information that will assist your practice. Talk to educators about your goals and needs if you`re not sure that it’s the right workshop for you. Talk to colleagues that have attended the training already if it`s been previously run and how they found it, time is precious, and you want to be getting the training you expect!  Just attending a workshop or webinar whilst a great way of meeting your CPD hours is not the sole intention of CPD. How will you implement what you have learned into practice? How has the training enhanced your knowledge and work role? What do you need to do next? More important than the certificate you may receive is holding onto any notes you have written at the training, better still a small reflection on what you have learned, how you will use it to improve practice and where to next.

2020 Permobil education will continue to provide educational opportunities around Australia and New Zealand. We have a range of new and existing workshops that will be run face to face around Australasia. Watch out online as we will be releasing these new additions very soon.

We will also continue to develop our webinar platform for more product specific training and of course our weekly blog! Over the next few weeks Sergei and Mal will be sharing some exciting and informative real-life experiences through our blogs and Rachel and I will return next year with the clinical blogs.

On behalf of the clinical education team and Permobil we would like to thank you for your continued support of our Blog this year and wish you and your families safe and happy holidays!

 

Rachel and Tracee-lee

To pommel or not to pommel, a look at adduction points of control

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Historically known as a Pommel or an Abductor, the new ISO terminology to describe this product parameter is a medial thigh support. This support can be independent of the seating (attached to the seat pan of the mobility base) or built into the cushion through the contours of the cushion itself.

Abduction and adduction of the hip joint are a continuum; neutral positioning is when the knee joint and hip bones are in line and symmetrical. If the knee is medial (Knees together touching) the hip joint is adducted. If the knee joint is lateral to the hip joint (Knees apart), the hip is abducted.

 

 

We frequently refer to the sitting position being as neutral as possible and we know if the wheelchair is too wide this has a negative impact on the shoulder joint for self-propulsion. So why do we use medial thigh supports in seating? When do we consider its use? What are the disadvantages of this type of support? We also know that the larger the base of support the more stability gained, abduction increases our seated base of support thus can be a preferred position. Body dimensions may also require a more abducted seated position, so why not sit everyone abducted?

In addition to forcing self-propulsion from a vulnerable position (in shoulder abduction), the increase in the width of the seating may also decrease accessibility in some environments. The clinical reasoning process needs to consider the hip ranges of motion established in a MAT assessment, tone patterns, proximal stability of the pelvis, and users’ functional goals to determine the seating parameters. What kind of supports are required based on the capacity of someone to gain functional support and stability?

 

                                  Abduction                                                             Adduction

                                                                                     

  

 

 

 

 

 

 

 

 

 

 

 

 

If a femur is positioned in more abduction than there is passive range, the impact on the pelvis will be seen with the pelvis rotating in the same direction to enable the femoral position.  This is commonly seen when a non-reducible wind sweeping position is not accommodated. Wind sweeping is the tendency for both limbs to sweep to one side – one hip will be abducted and the other adducted.

Longitudinal hip surveillance studies have provided us invaluable information on hip migration, causations, high risk group identification and resulted in guidelines such as https://www.ausacpdm.org.au/wp-content/uploads/2017/05/2014-Aus-Hip-Surv-Guidelines_booklet_WEB.pdf - which is an excellent resource.

 

 

 

The resource explains “Progressive displacement can result in asymmetric pressure that may deform the femoral head and or acetabulum (also termed acetabular dysplasia). Hip dysplasia may lead to degeneration of articular cartilage and pain25. Problems with limited range of movement and pain can interfere with function, ability to be positioned, hygiene and personal care. In a large subset of children the progressive displacement can develop into dislocation of one or both hips (Cooke et al, 1989).”

For anyone working or caring for young children with Cerebral Palsy and mobility impairment, potential risk groups have been identified and are encouraged to be referred to a hip surveillance program. Seating positioning recommendations for these children is likely to include some abduction for either chair or bed positioning.

One thing a pommel is not is a load bearing surface or a safety stop! When someone does not have the hip flexion ranges to sit with the hips bent at 90 degrees they are likely to “slide” out of the seating as they try to open their hip angle to meet the seat-to-back angle of the seating. I have been involved in cases like this where the support people then ask us to make the seat more ramped – based on the anti-thrust seat concept they may have had as a child or seen others utilising. If they do not have the range to sit in a 90 degree seat-to-back angle, raising the front of the cushion will only make it more difficult to maintain a flexed hip. They will continue to attempt to open this angle by sliding into posterior pelvic tilt (PPT) – see my previous blog for more on that.

If there is a pommel fitted this is often all that is holding the individual in the seating if they don’t have the capacity to bend their hips enough. When doing custom seating I would often have support workers or carers asking for this pommel to be larger as it stopped the user from sliding out. If we are prescribing AT, It is part of our job as a therapist to be able to articulate and educate what the points of control are and how they can benefit someone’s positioning and ultimately their function.

 

             A Dreamline Swing-Down Abductor Pommel

So, what is a pommel? What point of control is it addressing? The purpose of a pommel or leg troughs in a cushion are solely intended to reduce the level of adduction. The ongoing implication for adduction includes instability, increased difficulties with personal care and hygiene tasks, increased pressure risk at the knees and of significant concern, increased risk of posterior hip dislocation especially for those individuals who have never had opportunity of the hip fossa fully developing through walking and weight bearing.

When considering a pommel or a support to decrease adduction, there are several factors to consider. Should it be integrated into the cushion? This is likely to be determined by factors such as transfer style. Should it be removable? What environments is the user in requiring support? Can the support workers easily fit and remove it as required? How high is it? Generally, it does not need to protrude above the user’s thighs. What angulation can be achieved? Can it be adjusted for ongoing needs?

Do you want to know more about product parameters, MAT or functional seated positioning? Permobil offer a range of workshops including practical hands-on learning opportunities, blogs, workshops and webinars. Don’t hesitate to reach out to us for further information! Follow our blog to be the first to find out more details on our 2020 training opportunities which will be released very shortly!

 

Tracee-lee Maginnity

 

 

 

Seating Assessments  - The What, Where, When and Why

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It still amazes me when I am involved with a complex seating assessment and the user advises that this is the first time they have had a MAT assessment done or they haven’t had this type of assessment since they were a child. As I heard this again last week from an active full time wheelchair user with significant non-reducible asymmetries, I decided to talk about the MAT component of the seating assessment this week!

Are you doing MAT assessments as part of a seating assessment? Are you a wheelchair user that has never heard of a MAT assessment? This week we will take you through a seating assessment and discuss the what, where, when and why of a MAT assessment.

Getting Started

 

 

This flowchart is part of the online workshop for spinal seating NSW – there is a link at the end of the blog to the online course

What is involved in a mobility and seating assessment? If someone’s mobility impairment requires them to complete all mobility and activities of daily living from the wheelchair they should have a seating assessment. The seating assessment will include the assessor discussing the mobility needs, documenting historical information in relation to the impairment, looking at and measuring any existing wheelchair and seating, looking at the home environment, discussing goals, discussing other environments, the MAT and taking measurements.

Seating assessments are usually completed by Occupational Therapists or Physiotherapists. For some funding systems you need to see a therapist who has met the funder’s minimum requirements through a competency pathway, others may state an OT or PT, in which case you should look for a therapist who is experienced in Wheelchair and seating prescription.

A seating assessment should identify postural and functional goals and then taking a biomechanical approach, identify how to support the posture to meet the user’s goals. Both the therapist and the user should wear loose, comfortable clothing that will not restrict movement. For best outcome, a seating assessment should be done prior to the identification of potential trial equipment. The trial parameters will be identified at this assessment and then appropriate seating. (IMAGE A)

What is a MAT?

MAT is an acronym for Mechanical Assessment Tool. When completed in full it has 3 parts to it, the first part is the seated evaluation where the therapist will identify the posture whilst sitting in the existing chair. This part of the assessment can assist in identification of any postural issues currently being experienced in the existing system. The therapist will potentially feel your hip bones to ascertain how symmetrical you are sitting as well as making notes about how you are sitting and about your current equipment. It is good to articulate what is liked and not liked about your current equipment during this process. The therapist wants to determine what’s working and what could be improved so it’s good to talk about any difficulties being experienced with the current wheelchair or seating. Any places or tasks are identified that could be completed but are limited due to the existing seating or mobility device.

 

 

The next part of the assessment requires a supine evaluation (Supine means lying on back). This is around identifying the amount of movement in hip, knee and ankle joints. Essentially, they are looking at the capacity the body has to be in a seated position. The assessor will passively move legs into positions required for sitting and feel for tone and how much range of movement there is. It doesn’t matter if you can’t move your legs, the therapist will do it for you. They may measure this movement using a special ruler called a goniometer (Image 5, of goniometer ) or they may just take note of the movement range.

The 3rd part of the assessment is the simulation or the unsupported sitting component. This involves mocking up the ideal seated position based on the information from the first two parts of the assessment and taking measurements in this position for any new seating that may be required. This assessment is more crucial for people that are unable to sit without support as this will determine what and how much support the seating in the wheelchair needs to provide. The measurements are taken once the positioning has been determined to ensure the sizing will appropriately support needs. (Image 6 MEASURMENTS IMAGE)

When is a MAT done?

A MAT will usually be done prior to trialling a new wheelchair or seating system. It may also be done as part of a review of existing equipment to assist in determining if that equipment is still meeting needs. A MAT can assist in determining if there have been any physical changes in posture or range from the last time the seating or mobility base was prescribed. Completion of a MAT will assist in identification of the correct supports so it should be completed prior to the identification of a trial wheelchair.

Where is a MAT done?

A MAT assessment should be done on a plinth (Treatment bed) this surface is firm so enables the therapist to determine the movements fluidity and range without the impact of a soft surface hiding the movements. This is why seating clinics will often get clients to attend an assessment at their facility prior to setting up a trial at home. Some modifications to the MAT process may be necessary if completing in a person’s home or community setting without access to a plinth; If the seating assessment is completed in the community the therapist may bring a massage table. If done on an air alternating mattress, consider putting it to transfer mode or deflating it. If appropriate the assessment can sometimes be carried out on the floor.

 

Why is a MAT done?

By biomechanical design, people are not built for sitting, our skeletal system would have very different shaped sitting bones if so. A MAT is completed to assist in understanding the capacity of a person’s seated position. If postural tendencies and reductions in range are not considered they can have a negative impact on positioning, pressure risk and function. By working out what position is optimal, the required supports can be identified to support that position and then replicated with a trial of potential equipment.

To effectively identify seating requirements, points of control and required supports, it is best practice to perform a MAT as part of the seating assessment.

If you are a therapist and work with users to identify mobility and seating equipment, then keep your MAT skills up to date! There is an online course you can do here: https://www.aci.health.nsw.gov.au/networks/spinal-cord-injury/spinal-seating/module-3/the-mechanical-assessment-tool-mat

We offer several hands-on workshops and education opportunities to assist in learning more about MAT or building confidence in skills to complete this assessment.

Contact tracee-lee.maginnity@permobil.com to find out more information. Our education team is also happy to discuss any learning opportunities or clinical dilemmas. 

 

 Tracee-Lee

Oceania Seating Symposium 2019 – A recap of the conference

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Last week over 450 delegates from all around the world gathered in Melbourne for the 2019 Oceania Seating Symposium. Permobil was there as a proud Platinum Sponsor. The International Seating Symposium first started in Vancouver in the early 1980s, alternating between USA and Canada each year. The symposium has continued to grow and has assisted the development of partner conferences in Ireland, Brazil, Asia and now Oceania!

It’s now a premier meeting attracting dedicated clinicians, researchers, manufacturers, and others who work in the area of seating and positioning, and wheeled mobility.

 

 

The first Oceania Seating Symposium (OSS) was held in Rotorua, New Zealand and was hosted by Seating to Go, a leading assessment and education provider.

This year was Australia’s first time to host OSS at the Melbourne Cricket Ground, and it was a huge success by all accounts.

Melanie Tran is a university student and UX designer for Ability Made and Hire Up. She opened the 3 day event with a Keynote on “How Opportunities Can Be Created Through Design and Technology”.

Melanie is an eloquent speaker who provided an insightful presentation, drawing on her experiences

 

 

Melanie was followed by renowned Paediatric therapist Lisa Kenyon, who presented the latest research and shared some therapist conceptions (or should I say misconceptions) on accessing powered mobility. I hope she challenged paediatric therapists through her case studies of very young and complex children to enable more children to gain access to independent movement opportunities. 

Kelly Waugh from USA presented several papers and workshops over the 3 days that were very well attended. I attended her head and neck positioning workshop where we were reminded about determining points of control in relation to the centre of mass and the importance of understanding these concepts and the bio-mechanical influences of specific joints.

 

 

Permobil Clinical Education specialist Rachel Fabiniak presented two clinical workshops, one on alternative drive access and another on upper extremities and manual wheelchair propulsion.

The sessions were in high demand and very popular. Attendees were taking up every available seat!

Our education team also presented on seating and powered Active Reach on the product education stage, as well as having lots of clinical discussions on our expo stands where the therapists had an opportunity to get hands-on with a range of products.

 

oppo

rtunity to get hands-on with a range of products.

 

 

Permobil Clinical Education specialist Rachel Fabiniak presented two clinical workshops, one on alternative drive access and another on upper extremities and manual wheelchair propulsion.

The sessions were in high demand and very popular. Attendees were taking up every available seat!

Our education team also presented on seating and powered Active Reach on the product education stage, as well as having lots of clinical discussions on our expo stands where the therapists had an opportunity to get hands-on with a range of products.

 

 

There was a great range of topics presented this year and too many highlights! As well as all the learning opportunities, OSS also provided networking opportunities. The conference dinner gave attendees a chance to get together socially.

A local indigenous dance group gave a beautiful performance and Mal Turnbull warmed the crowd up as the evening’s MC. A very tasty dinner was followed by dancing and it was great to see everyone have a chance to enjoy the evening.

It was also great talking to the therapists about their experiences at OSS. Everyone I spoke to felt it had been a very valuable learning opportunity, with more than a few saying it was the best conference they had been to. Therapists came from all over Australia and New Zealand to attend and it was great to meet one of the scholarship recipients – a rural therapist who was selected by the committee after writing about how her practice would benefit from attending.

The supplier expo was very busy! We really enjoyed showing everyone the range we had on stand and the feedback around our new products was positive and constructive. Therapists got a sneak peak of the Pushtracker E2 in action with the SmartDrive. This officially launches today so if you couldn’t make it to OSS and didn’t see the webinar, get in touch with your local dealer who now has all the details!

 

Tracee-Lee

 

 

 

 

 

Seating and Positioning – Achieving the right posture

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This week’s blog comes to you from the sky as we head to Melbourne, for Australia’s first ever Oceania Seating Symposium! We are excited to have this conference here in Australia. If you’re attending, please stop by and say hello. Rachel has two clinical presentations and we are both also presenting on the product stage. I will share a few conference highlights next week but for this week’s discussion we will continue with a seating theme.

Posterior Pelvic Tilt (PPT) and associated kyphosis are one of the most common and avoidable seating positions. When we talk about the pelvis being the foundation in sitting, we are referring to supporting the pelvis in a neutral position, but is this all about the cushion? … yes and no! The cushion can assist in maintaining a neutral position but if there is a tendency for a reducible PPT the primary point of control is the posterior aspect of the pelvis, so essentially comes from the backrest. Before we delve deeper into this point of control lets look at some common causations of PPT based on the equipment provided and how a cushion can assist or work against the goal.

Identifying some common causations of PPT

The most common causation in an equipment induced PPT is when the seat depth is too long. This is a crucial measurement. If it is longer than the femoral length (Popliteal to behind Glutes with neutral as possible pelvis) the user has no choice but to roll back into PPT to gain back support. Think about your big deep comfy couch. This is often designed with a long seat depth. Think about the functional activities we do on couch…its more about relaxation. When we sit on this deep seat length and we can’t sit back any further whilst still having our knees in a flexed position, our pelvis must roll back into a PPT for us to have contact on the backrest. The same happens in a wheelchair seat.

 

The other time we frequently see PPT is when we have not accommodated shortened hamstrings or reduced hip flexion. In these instances the seat to back angle and/or the hanger angle of the leg rests need to meet the users needs and postural requirements, if these do not meet the range of motion (ROM) identified within the MAT assessment of the user there is often a constant postural battle with PPT as the consequence.

The Cushion

As discussed earlier the seat depth is crucial and as such the cushion is also important. We need to ensure that the cushion depth and placement match the user’s measurements. When considering the product parameters of the cushion we need to pay attention to the Ischial well and ledge. In some modular cushions there are some IT adjustment options (where the ledge is located and how deep the well is) ideally you want the ledge to be just in front of the ITs to assist in reducing them from rolling back towards PPT. The depth of the well and the materials in the well also need to be considered in relation to the positioning and support requirements. Placement of a pelvic belt will also assist in supporting the pelvis and are part of the point of control solution.

So, what happens when you have an end user who has an appropriate seat depth, a reducible PPT and you have determined the ROM is appropriate. Where is the point of control to correct this positioning and support a neutral pelvis?

Just as our back is not flat, the contours of the backrest should be such that they support the end users shape and postural tendencies. In paediatric seating we may be further trying to assist in the development of the natural curves within the spine.

If the wheelchair is for occasional use, an upholstery backrest may meet the goals and needs of the user, however if the wheelchair is used for all mobility or functional tasks it is essential to consider alternatives. For some users this may mean a tension adjustable upholstery backrest which can be adjusted to provide support as required however for many a rigid backrest will be needed to provide the best support. Assessors and prescribers need to be aware of how to appropriately provide support with a rigid backrest to assist in the clinical reasoning process. For some backrests we can adjust the angle of support within the mounting bracketry and if the user has trunk innovation this may be enough. For some users, a pelvic block cut from a firm foam and placed under the backrest padding can make a significant difference. Other options have bespoke adjustments such as the Boa system within the Acta backrest, which uses a reel and cable system to provide supportive contours. If more contouring is required consideration of a customisable backrest where you can build a pelvic block into the backrest such as using the BAC system with the Dreamline backs may provide the contouring and positioning chosen. Essentially it is dependant on the degree of impairment and overall presentation on how aggressive and what type of supports are required. In all instances however we are trying to provide a rear low force that assists in pushing the pelvis from PPT towards neutral as the primary point of control and then provide opposite and equal forces to maintain using the cushion and pelvic belt.

If you want more info on seating and positioning, please contact us. We have a range of workshops to assist you in your learning goals.

 

Tracee-Lee

 

 

 

Proximal Stability – Distal Ability

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In the world of therapy, we often hear the phrase, “Proximal Stability before Distal Ability”. Essentially, this is a principle of movement and relates to the development of core strength and stability at the trunk to promote movement and based on foundation concepts of kinematic chains.

The concept of kinematic chains was initially proposed by Franz Reuleaux, a mechanical engineer, in 1875. (F.Reuleaux, Kinematics of Machinery,1875). 80 years later, Dr. Arthur Steindler expanded upon Reauleax’s work and applied the concept to the human body and movement. Dr Steindler, MD, orthopaedic clinician and educator proposed that the extremities are rigid, overlapping segments in series and he defined the kinetic chain as a “combination of several successively arranged joints constituting a complex motor unit.” (Ellenbecker TS, Davies GJ. Closed kinetic chain exercise: a comprehensive guide to multiple joint exercise. Human Kinetics; 2001)

 

The human kinetic chain refers to the interrelated groups of body segments, connecting joints, and muscles working together and the portion of the spine to which they connect. Optimal movement requires structural alignment of the skeletal system and joints, and neuromuscular control. Impairment within any of these systems can affect movement. The upper kinetic chain consists of the fingers, wrists, forearms, elbows, upper arms, shoulders, shoulder blades, and spinal column. we must first have a stable chain of muscles that run from our core muscles to our shoulder to our elbow, wrist and then to our fingers.

We will now focus on the upper kinetic chain and the provision of assistive technologies to support proximal stability and consequently increase functional positioning in a wheelchair. So how can we support or create proximal stability and enable increased functional positioning?

 

 

For wheelchair users we need to first consider the foundation of the spinal column in a seated position, the pelvis. Correction of a reducible pelvic obliquity or rotation is one of the ways we can promote a stable base of support. When completing a seating assessment, it is important to consider the pelvis position in all planes and use sound clinical reasoning to identify the points of control. This in turn helps us identify the required product parameters of the seating which will assist in identifying appropriate seating options. 

Seat depth and width also need to be considered in order to gain proximal stability. If the seat is too wide the pelvis may lose lateral stability, too short or too long and it may be difficult to maintain a neutral pelvis in the sagittal plane. Last week’s blog looked at pelvic positioning belts which when correctly positioned can assist in pelvic stability.

Once the pelvis is stabilised, we can look to the trunk. For individuals that present with spinal asymmetry, when the posterior of the trunk is supported with appropriate contouring, we often find that the lateral supports don’t have to ‘work as hard’ resulting in less force being required.

For manual wheelchair users the chair configuration can also assist with Proximal stability;  “When a person has paralysis, hypotonia, incomplete motor coordination, an amputation, fatigue, impaired sitting balance, and they are unable to use their hip, thigh and trunk muscles for balance, the wheelchair or the seating system must do it for them. Seat slope creates that passive pelvic stability through the configuration of the wheelchair which allows the person to have better upper extremity function and endurance to perform their daily tasks.” (see Permobil USA Blog for more information on how seat slope and ergonomic seat can assist with proximal stability https://hub.permobil.com/blog/ergonomic-seating-manual-wheelchairs )

For power wheelchair users, proximal stability can assist in better control in chair operation. Arm rests should be at a height that stabilises the forearm with the shoulder in a neutral position; it is harder for many users to have fine motor control when the shoulder is abducted. If you have good proximal stability and the capacity for independent mobility but still struggling to control the mobility base, then consideration should initially look at a centre-mounted joystick position. This enables further stability of the more proximal shoulder and elbow joints, sometimes you may need to consider alternative access methods.

 

 

If you want more information on seating and positioning or mobilising wheelchairs, please contact me or alternatively Rachel, as Clinical Education Specialists we are here to assist you in ongoing educational opportunities including webinars, workshops, courses and one-on-one support. If you found this blog useful please feel free to share the link with others and sign up so you don’t miss future ones.

 

Tracee-Lee

 

 

Restraint or Enabler...Part of the prescription or an afterthought?

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Over the past decade the debate has continued around the world…is a pelvic belt a restraint and therefore classified as a restrictive practice? Or is it part of the seating solution supporting functional postural positioning? This week we will look at the definitions of restrictive practice, restraint and the functions of pelvic belts.

Within the clinical reasoning process of a seating assessment, we need to identify points of control. If we consider the movements of the pelvis in the coronal plane we know that a neutral or a slight Anterior Pelvic Tilt (APT) is a more functional position than Posterior Pelvic Tilt (PPT). When a belt is applied to assist in maintaining a neutral position, we refer to this as a postural support, therapeutic support, (note the word support) or an enabler because by providing support we are enabling function.

 

 

With the pelvis as the foundation think about how we can successfully increase distal ability…by providing proximal stability! It is also important to understand these types of supports and postural needs so that this can be appropriately explained to our clients. They can then make an informed choice around their equipment options.

Pelvic positioning belts are often seen as being a safety belt, this is likely due to the use of seat belts in motor vehicles. In a motor vehicle the belt is a restraint, its sole purpose is to restrain someone in the seat in an accident. If a wheelchair is being used as a seat in a motor vehicle for travel the positioning belt does not negate the requirement of a seat belt in the vehicle. They each have a different purpose!

“Restrictive practices are defined as any type of support or practice that limits the rights or freedom of movement for a person with a disability”. There are 6 types of restrictive practices recognised:

• Seclusion
• Mechanical
• Chemical
• Physical
• Psycho-social
• Environmental

We will now focus on the two areas of restrictive practice that are often referred to with the application of pelvic belts – physical and mechanical.

Physical
• A physical restraint is the use or action of physical force to prevent, restrict or subdue movement      of a person’s body, or part of their body, for the primary purpose of influencing their                    behaviour. (https://www.ndiscommission.gov.au/regulated-restrictive-practices)

Mechanical
• This is when something is put on a person to stop or make it harder for the person to move or to       control their behaviour.

• Sometimes a device is put on a person to help them to move or to stay healthy. This is called a          ‘Therapeutic Device’. This type of device is OK as it can help reduce pain, improve health or help        the person do an activity.

 

 

It is OK to use a therapeutic device when a health professional like a doctor or occupational therapist has approved it. The person with disability also needs to say it is OK. (Voluntary Code of Practice for the Elimination of Restrictive Practices – Disability Services Commission / WA Government)

 

Both definitions relate to behaviour and if being used in this way they meet the definition of restrictive practice. So, when is a pelvic belt a restraint and when is it an enabler…?

 

Ask yourself the following question:

 

 

 

We know that there are facilities out there that have very stringent restrictive practice policies that continue to impact on the prescription of a therapeutic support. It is still crucial that if you have identified the need for a positioning support, that you own it! Don’t include the recommendation based on being told that the facility has a restrictive policy and will not allow belts. Best practice indicates that you still make the recommendation and document the reasons how it will enhance function.

If you want more information on positioning supports, we offer educational workshops on seating and positioning and are always available to help you. Feel free to contact me at tracee-lee.maginnity@permobil.com.

 

 

Tracee-lee Maginnity
Clinical Education Specialist

Tracee-lee Maginnity joined Permobil Australia/New Zealand 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.