DME

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.

A Thief Gave Me The World

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This week we're pleased to feature Robbie Vance and his uplifting account of how getting his power wheelchair opened the door to opportunities and helped him recover many parts of his life that facioscapulohumeral (FSH) muscular dystrophy had taken away. 

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I fought it. The symbol of weakness sat by itself in the guest room where I never went. Whenever I struggled to walk past the door, I purposefully averted my eyes, looking down or away. I did anything I could to avoid dealing with the wheelchair the young guy delivered in October of 2007. It was an ominous sign of my fading independence that I hated both for its invasion of my house and what it stood for.

My thirtieth birthday came just days before the chair became my unwelcome roommate. From the time I was a six-year-old playing tee ball, facioscapulohumeral (FSH) muscular dystrophy had been stealing from me. It started by stealing my ability to run and play like the other kids. Then, it stole my ability to raise my hand over my head to be recognized in class. It took my ability to get up off the ground when I would trip and fall. I tripped and fell more often because it stole my balance and my ability to pick up my feet sufficiently when I walked. It stole my self-confidence through the embarrassment that resulted from my public displays of physical awkwardness. It stole my ability to climb stairs followed by my ability to get up out of a chair without great effort. It stole my desire to go places in public like restaurants or movies where I was sure everybody would be pointing at me and whispering to their friends about the crippled guy. It took my ability to fit in, to go somewhere and not be noticed, to not be viewed with fear or pity, to not be the guy that people are afraid to approach, to not be assumed to be mentally challenged because I can’t do the Macarena. 

Before going out into the world, I did a cost-benefit analysis of the calculated risks and levels of reward. Whatever I wanted or needed basically had to be accessible from my truck window or it had to come to me. I would only go to work or to visit friends and family where I knew there wouldn’t be any major impediments to my limited mobility. If I needed food, it was delivered, came from a drive thru, or I would go to Mom’s kitchen across town. These limitations caused me to gain a good bit of weight, unfortunately. Eating mostly fast food and pizza, coupled with my inability to exercise, exacerbated a vicious cycle where the extra weight made it harder to get around which made me exercise less which made me gain weight and on and on.

I rarely let anyone take my picture or videotape me. If I didn’t have to see my physical awkwardness, I wouldn’t be reminded of it, and I wouldn’t have to deal with it. But inevitably, I would trip and fall or something else embarrassing would happen, and the reality of my diminished physical capabilities would kick me squarely in the jaw.

While the necessary daily activities like getting out of bed and getting dressed for work got more and more difficult for me as the days, months, and years passed, I tried not to let it show. I was fiercely independent and pressed my insistence to remain independent much further than I probably should have. I should have been using my chair a long time before I did, but it sat in my guest room for the first few months after being delivered, being used for nothing more than the infuriating target of my disdain, the harbinger of my inevitable future as a helpless cripple. I should have taken many other steps to deal more realistically with my needs much earlier than I did, but I was hard-headed, as is the case with many in my red-bearded Irish lineage.

The first time I used my chair in public was on December 29, 2007. It was a cold, clear day with a stiff breeze blowing from the northwest and swirling through the Liberty Bowl stadium in Memphis. Dad and I drove up for the late afternoon kick off to see our alma mater, Mississippi State, beat the University of Central Florida in the first bowl game I’d ever been to and the first football game I’d been to since I was in grad school.

The temperature nose-dived as the sun dropped below the rim of the stadium, and the game didn't provide much of a distraction from the spreading frostbite as it was a real snoozer. Despite not being able to feel my feet or lower legs, I had a great time just being somewhere new, and I even hated my wheelchair a little less than I did before we left home that morning. It was the first time I’d been able to get around without struggling and exhausting myself in a good many years.

My football outing changed my attitude toward my inanimate roomie. While I wasn’t ready to be friends just yet, I didn’t want to shove a grenade in its figurative tailpipe ether. Progress is progress. Right?

In January 2009, I received a promotion at work, and one of my new job responsibilities was to organize a meeting involving the Governor and a few other high-level elected state officials. This meeting was to take place in February in the Governor’s conference room, which was in a building a few hundred yards away from my office. It was too far for me to walk, and parking near the building wasn’t abundant. So, I decided it was time to bust out the new ride and roll in my office like I didn’t give one single damn what anybody thought about me showing up in a chair. 

All it took was that one day to change my outlook, and not just on the chair that I’d come to view with apprehension—already a step up from it being the vile demon waiting to steal everything that FSH hadn’t already absconded with. That day, the world opened up to me with opportunities abounding. I began exploring the places that I’d been unable to go on foot like the local Braves minor league ballpark, restaurants that don’t serve food in waxed paper, Styrofoam, and cardboard, college football games at my alma mater, concerts, dates, and most anywhere else you can think of—except shopping. I still prefer online shopping. #freeshipping

Last summer I sat down in my 3^rd power chair, an all-black Permobil F5 Corpus VS that is by far the most comfortable seat I’ve ever owned. Then, a few weeks later, I did the most out of character thing I’ve ever done, and I thoroughly enjoyed every second of it. I took a trip to Nashville to visit Permobil and have my photo taken for their new website. I rode 7+ hours to Nashville to do the one thing I liked doing less than just about everything else in life. Over the course of the four days I was there, I got to meet and make friends with lots of great people and have my photo taken by a fantastically talented professional photographer who managed to accentuate my positives while cropping out most everything that made me uncomfortable about myself. It was not only a fun trip and a much need vacation from my everyday life, it was one of the most therapeutic activities I can remember and had a profound effect on my self-image.

Despite my fears, being in a chair has helped me recover many parts of my life from the FSH, instead of taking what was left. I’ll be 40 next month and even though the FSH is still progressing in ways predictable and otherwise, I’m thankful for every day I get to spend on the sunny side of the dirt. I don’t know what’s ahead, but I can’t wait to find out. I just hope it has a ramp.

Client Centred or Funding Dictated? 

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Over the past couple months, we have been discussing power wheelchairs. We covered everything from drive wheel configuration to power seat functions and even the integrated technology like Bluetooth. I hope that you were able to learn one or two new facts throughout this time. What happens now? As we move onto the next topic series, I first wanted one more blog to really discuss why this all matters. It is easy to read a blog and then just continue on with our busy days. Do we take the time to read and really think about how our clients can be impacted by the equipment they receive?

This can be a hard discussion to have or to even think about. For many and most countries around the world, we talk about the idea of client-centred care. This means that we are completing our treatments, planning our goals, and prescribing equipment around the client. This is what most of us discussed and learned in our university. However, often we find that we are limited in this client centred approach. What is this limitation? FUNDING! Every country that I have lived in, worked in, or visited have all had the same barrier – Funding. We can allow funding to take over this client-centred approach and it then turns into the funding guiding our decisions on what is best for our client. Why does this matter? Our founder of Permobil perfectly answered this question so many years ago:

Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our everyday lives.

So, does funding have it all wrong? No, this is not a blog to be negative to any funding. We have to remember that funding is guided by a LOT of different pieces. Some of these pieces we cannot change. However, when appropriate we can discuss and demonstrate how important it is to build and design the equipment to the client versus fitting the client into funding. This also means that we can demonstrate to our funding bodies/systems how client centred prescribing can lead to improved outcomes, increased function, increased independence, and an improved quality of life.

Many funding systems will allow the therapist to write an assessment or justification to explain why a piece of equipment is necessary if it is outside of the normal funding amount, code, or list. This can be overwhelming to many therapists to write this justification and for many good reasons. Sometimes we can be aware of the improvements in a client’s function, independence, medical benefits, but we are unable to understand how the equipment is making this change. Power wheelchairs, seating products, manual wheelchairs, they are all complex. A high-quality product is designed utilising the highest amount of research, an understanding of materials, and engineering principles. You might understand that one power wheelchair is easier for the client to maintain their position over uneven terrain versus another, but are you able to discuss how this can be related to the suspension, seating components, and their drive wheel configuration? This is where the challenge can come. How as therapists are we supposed to understand both our clients and the equipment to this high degree? As you continue to prescribe equipment this will become easier and you will continue to learn, but in the beginning remember that you have resources to help!

Reach out to your mentors, educators, manufacturers, etc… to help provide you with this information that you need. Ask the questions! There is so much information and research out there to help explain why your client might benefit from a certain function or design of their equipment.

The final thought I want to end on is to keep pushing. We have to remember how far we have come and that we have to continue to keep pushing for our clients. If we do not attempt to ask for funding on equipment that we believe is justified in improving our client’s lives, then we will never see a change in the funding. The funding system needs to hear that what they are funding is not always enough when that is the case. They may not be aware of new features and new technology and how this impacts your client. Unless you write a justification or assessment to tell the funding system that your client requires something different, we cannot blame them for not funding it. Remember to appeal too! Perhaps your first attempt did not fully explain why this equipment is necessary. If you get a denial, think about if this equipment is necessary to your client. If the answer is yes, go back to your resources, gather more information, and try to explain this again. If we do not appeal a denial, then we are essentially agreeing that this equipment is not necessary for our clients. I know this can be overwhelming at times, but remember we are here to help!

New Zealand Therapists!

I will be travelling across New Zealand at the end of November to come and talk about power wheelchairs and how the design and technology can impact our clients’ lives. Reach out to your local territory sales manager if you are interested in attending the event near you! You can always reach out to me directly at Rachel.Fabiniak@permobil.com.

Rachel

Why Switch from Switch Control?

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Mouse Emulation on an iPad?  Moving a cursor on a screen on an iPhone?  Did I just read that correctly?  Yes, you did!

When Apple release iOS 13 in September, in addition to new Memojis, an amazing new accessibility function was also released, which gives consumers who prefer Apple products more choice as to how they interact with their device (consult Apple to find out if your device is compatible with iOS 13)

Prior to this release, options for a person using either direct access or indirect access through Permobil iDevice, they were required to use Switch Control to navigate their icons, menus, and advanced scroll functions.

The best thing about this update, is that those who prefer Switch Control can still use this access method while trying out the new mouse emulation to see which is the most effective or efficient for them. The decision could depend on a few factors: drive input, wheelchair or external switch access methods, range of motion, strength, activity tolerance, what types of activities they will be completing with their phone or tablet, and of course, their individual preference.  

Now, there is a choice!  Consumers can now choose if they would like to use mouse emulation instead when using an adaptive Bluetooth mouse, such as the one that come standard on a Permobil PJSM or CJSM joystick, or OMNI2 display. 

To use and explore this great Apple Accessibility function with your Permobil Bluetooth mouse here are a few instructions.

Contact Rachel Fabiniak, your Permobil Clinical Educator, at Rachel.Fabiniak@permobil.com for any Permobil questions.

Phone:

 Download iOS 13 to your iPad/iPhone and make sure Bluetooth is turned on

1.  Settings->Accessibility->Physical and Motor
2.  Touch->AssistiveTouch->ON
3.  Pointer Devices-> Devices->Bluetooth Devices 
4. Tap Bluetooth Mouse 1

              a. You can change the cursor speed, size, and color

              b. You can also use dwell click

              c. Show onscreen keyboard

              d. Always show menu

              e. Can customise assistive touch menu

Wheelchair

1      On your joystick, go to settings (push and hold top left button) and Turn Bluetooth

        Mouse 1 "ON”

2      Exit settings

3      Toggle to Bluetooth Mode

4      Place joystick into pairing mode (>>>>>)

5      Bluetooth Mouse 1 will appear on your phone’s BT menu.

Learn more here:

 https://support.apple.com/accessibility

 https://www.ablenetinc.com/downloads/dl/file/id/798/product/515/ios_13_switch_control_user_guide.pdf

Call for accessibility support

 To contact Apple Accessibility Support over the phone in English, use these numbers:

•          Australia: (61) 1-300-365-083
•          United States: 1-877-204-3930
•          United Kingdom: 0800 107 6285

Jennith Bernstein

Permobil US Clinical Educator Manager

Jennith Bernstein, PT, DPT, ATP/SMS: Jennith is a Physical Therapist based in Atlanta, Georgia.  She spent 10 years at The Shepherd Center, focusing her time in the Seating & Wheeled Mobility clinic for 7 years. Jennith completed her Masters in Physical Therapy at North Georgia College & State University and return to complete her transitional DPT at University of Texas Medical Branch in 2014.   Jennith has served as a volunteer teacher at the Universidad Mariano Galvez in Guatemala, instructing spinal cord injury curriculum as well as seating and mobility.  Jennith has presented at national and international conferences such as RESNA, ISS, LASS, Expo Ortopedica, and the APTA NEXT conference. Jennith joined Permobil as the Clinical Education Manager for the Central Region in 2016.

Mecenzi’s Story

“I go places and people look down at me, I would rather look them in the face.” – Mecenzi

If we have the ability to fully access and participate in our environment, we may forget that this human right is not possible for everyone.  Think about your daily life.  Can you reach the counter in your kitchen to make a sandwich, or reach inside the refrigerator to grab a drink?  What about reaching up in your closet to get your clothes?  That is just in your home.  Now think about experiences in your community.  Can you look face to face with your friends and family? Can you give your loved ones a hug without an awkward bend over shoulder in your face outcome? How about accessing counters at a restaurant to pay your bill?  For many individuals with a mobility impairment their environmental access is greatly limited.  It’s not just environmental access though.  How would you feel if you had to sit down in a chair at a party while everyone around you was standing and talking? For some individuals with a mobility impairment, they find it difficult to fully interact with their peers when they are unable to look them in the face.  For individuals with mobility impairments it might not just be accessibility and peer interaction but returning to or choosing a career path that typically requires standing throughout the day.  While accommodations can typically be made, what if instead of adapting the environment we adapted the individual’s mobility device?

Today I want to share with you Mecenzi’s story of herself and her new F5 corpus VS.

Mecenzi’s story, as you will see in the video below, illustrates how with the assistance of the F5 Corpus VS, Mecenzi has greatly improved not only her independence, but how being able to stand up makes her feel. 

The F5 Corpus VS may not be for everyone, but it is time for everyone to have access to products that will allow for the greatest independence possible.  In this case, the F5 Corpus VS has given Mecenzi the mobility that she requires to meet her goals and allow her the freedom and ability to access her environment. 

Apart from the social benefits Mecenzi and her family love, standing wheelchairs can also deliver potential health benefits. We will explore some of these in future blogs.

Please check out the link below for more information on the F5 Corpus VS: 

https://permobil.co.nz/2019-f5-corpus-vs

“Every person has the right to have his or her disability compensated as far as possible by aids with the same technical standard as those we all use in our everyday lives.” Dr. Per Uddén, Permobil Founder

Rachel