Blog posts of '2019' 'July'

Shoulder Prevention: Are we doing enough?



We have been discussing shoulder preservation over the past couple months and today I want to finish our discussion with this video. When I watched this video, I became overwhelmed with several emotions. I must have watched this clip 10 times in a row. Over and over, each time thinking about all of my clients, individuals with a mobility impairment, but the thought that I couldn’t stop thinking about was – Are we doing enough?



Watch this video. Watch it at least twice. The first time you might laugh seeing the challenge for the one end-user at self-propelling up the ramp versus the other end-user who is utilising the SmartDrive power assist. The second time you watch this, what do you see?

For me, I see two things. First, a strong woman pushing to her limits to overcome that ramp. She should be proud, as many of us might not be able to accomplish such a task, but I can’t help but also see someone who has to struggle to achieve the same outcome as the person next to them. Every time I watch this video I think about her shoulders, her goals, her independence. Is she able to get everywhere she wants to go, safely and independently? Or, is she limited because of her environment and her equipment? What happens to her shoulders a year from now? 15 years from now? Will she be able to maintain her independence and navigate in all the environments she encounters? Are we doing enough?



The founder of Permobil, Dr. Per Udden, so perfectly stated, “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.”. I think about this statement, this video, and I know that as an industry we have to do more.

Now, it’s important to say that many end-users may choose to not have a power assist or prefer even if they have one to propel independently up ramps for example, that is their choice and as a therapist we recommend what we believe to be safe and beneficial to the client. However, how many clients are not able to receive the equipment necessary for them to live their lives to this same technical standard? This is where my question comes in… Are we doing enough?

This question is for everyone: The manufacturers, end-users, therapists, dealers, families, and carers. Are we doing enough?

No matter what your role above may be, we all have to work together to make sure that individuals with mobility impairments are receiving equipment that is necessary for them to complete their goals and to live their lives to the same technical standard.

There is a massive task for manufacturers to continually design and develop products to meet these needs and while gaps exist, we see some amazing products coming out to help support individuals with mobility impairments.

Then there is a gap. We often see many of these products, but end-users are unable to access them. This can be for many reasons, oftentimes this can happen from a lack of knowledge of the products, not understanding the client’s needs or goals, limited resources, and limitations of funding.

No matter where this gap comes from, we have to all work together to help close these gaps. During the actual assessment and evaluation this means working from a team approach. If we have the therapist, client, family, carer, and dealer all working together in the assessment we see the best outcomes, but we can’t just stop there.

Funding. This can be a very hot topic around the world. We see countries with funding systems based on the client’s functional needs, the client’s medical necessity, or given an allocated fund that they can use to their discretion. We see funding systems with strict guidelines in what is/is not funded while other systems are open to understanding why the recommended equipment is necessary.

The purpose of this blog is not to discuss funding and it is not to talk negative about any country’s funding system. While we can shift the question to the funding bodies and ask, “Are they doing enough?”, instead I want us to first shift the question back to our industry and ask again, “Are WE doing enough?”.



As an industry, have we done enough to show the impact that this equipment can have on an individual’s life? How often do we see videos like the one above? Does the funding system understand the impact that a device or piece of equipment can have on an individual’s life? Has this been explained? For many countries this is discussed by the therapist on the request for funding, but what about after? Once the equipment has been approved and delivered, do we show this impact?

Just as in the assessment we work together as a team, we have to have this same team approach if we want the community outside of our small industry to understand.

If you are a therapist this means educating the community, the clients, and the families. Talk about what it is you do and why you do it. Share your stories of success. Work together with other therapists to share your knowledge and experiences. Attend conferences, seminar, and workshops to not only advance your knowledge, but to support your industry.

If you are an end-user, family, or carer – Show and talk about what your equipment does for you! It doesn’t have to be a power assist, this can be your manual wheelchair, your power wheelchair, etc.… We want everyone within and outside of the industry to see the impact that a device or piece of equipment can have on someone’s life. This is how we as an industry become better. This is how we are able to start having those conversations with funding bodies. This is how we can make change happen.

Our world is no longer big. As we continue to progress with technology, we see that our world becomes smaller. We can interact with people across the world. This means that we can work as a team. Maybe you live in a country where you have access to great equipment. Have you thought about how sharing your experiences could help in other countries where funding/resources/awareness is limited?

No matter which part of the team you are, we all have a part to play and just as any team – the more we can work together the better the outcome of success.

If you are an end-user of one of our many Permobil products we want to hear from you! This includes Permobil, TiLite, ROHO, and SmartDrive. Share with us your story of success. Please email or your local Permobil Territory Sales Manager.



Shoulder Prevention: Let’s Talk About Power Assist



When we are considering a manual wheelchair are we considering a power assist option?

We have been discussing shoulder preservation and how it relates to the weight of the wheelchair, the configuration of the wheelchair and to the individual and their pre-morbid shoulder health. We have also discussed how mobility is NOT and should NOT be exercise. So, how do I know when I should be considering a power assist option? First, we have to look at each individual end-user/client, their goals, environment, and any current shoulder pathologies.

The Goals:

This is one of the most important pieces of information that we need to understand from the assessment. As the therapist we can often just ask the question about what goals the end-user has, but do we really hear all the goals? Often the client may be able to express all of their goals, but just as most of us, we are not always able to express or understand our goals. I like to think about this as when someone approaches me and asks, “Where do you want to be in 5 years?”. This is a difficult question if I haven’t had time to think and prepare an answer and often it is hard to know this answer without having a deeper discussion. This can be the same when talking about goals for the client. If this is someone going into their first manual wheelchair, they may have no idea about what is possible. They may have goals that they want to achieve, but believe it is not an option. Or, perhaps they are not able to even generate a list of goals. They might list a goal or two when asked just to appease their therapist, or just to try to participate. Then we have to think about the clients with cognitive or communication deficits. Does this mean that they don’t have goals? It is crucial that we as the therapist or as any member of the team spend time to discuss goals with the end-user, their carers, and family. Their goals will help us to better understand the needs of their mobility device and if power assist should be considered.




If you are a therapist going into the community, you can see first-hand the client’s home environment but remember there is a lot more to someone’s environment than just their home. I like to think about this like 24-hour positioning. I need to consider every typical environment that the end-user encounters not only just in a one-day time stamp but does this change across different days of the week. Like myself, on the weekdays I may only encounter my home, car, and work environments, but on my weekends, I prefer to spend my time outdoors. As a therapist, it is important that we are able to ask the right questions to better understand the environments that will be encountered.

Shoulder Pathologies:

Have you ever asked someone if they are in pain and they respond no, but then within minutes you find out they take pain medication daily? There are many reasons that pain is not discussed during an assessment. This can range from the question not being asked, the client not wanting pain to keep them from their goals or activities, the client may forget that they are taking pain medication, etc…. No matter what the reason is, it is crucial to determine if the client has any underlying shoulder pain or pathologies. This doesn’t mean that they are not appropriate for manual mobility, but it does help to determine if a power assist option should be considered. 



While there are still many other important aspects of the assessment to consider, this is a good starting point. Take this information you gather from the assessment and determine if the client is at a risk of further shoulder pain/problems, not being able to navigate in their environment, or if they are not able to achieve their goals without the use of a power assist device. If the answer is yes to any one of these, then discuss with your client and dealer/supplier power assist options.

I often hear that therapists just don’t think about it during the assessment of trial. I know there can be a LOT to consider, but power assist can truly change a client’s life.

Shoulder Preservation: Functional Mobility versus Exercise



As we continue our discussion on shoulder preservation one common question that comes up from therapists, end-users, and families frequently is: Should Propelling a Manual Wheelchair be Exercise?

This question comes in many forms. Often the therapist has the dilemma of worrying about the end-user being as independent as possible, the idea of maintaining the end-users’ function, and keeping in mind the costs associated with different product options. I have also heard a few therapists’ express concerns that if their client does not maintain an “active lifestyle” they could gain too much weight and not be able to fit into their system. The end-users and families usually tell me that they are concerned about the idea that “if they don’t use it, they will lose it”. This is a common statement that we as an industry made popular and unfortunately continues to be used every day.



Let’s now go back to the question: Should Propelling a Manual Wheelchair be Exercise? To answer this, we must start by defining what functional mobility is. Functional mobility is the ability for someone to move around in their environment. We ALL have to move around in our environments, whether it is our home or community, to be able to complete all of our daily activities. For an individual with a mobility impairment, this might mean that you need a walker, orthotics, or for this discussion, a manual wheelchair to move around in your environment.

Using myself as an example – for me to complete my daily activities I will move around by walking. This is not exercise for me. I need to be able to move around all day. Now imagine if I had to skip or run every time I moved. This would be not only exhausting, but also a lot of work for my body. I would likely not be able to complete all the tasks or participate in all the activities that I wanted to each day if I had to skip or run everywhere. Therefore, my options would be to either rely on someone else to help or I would simply not be able to participate.

Keeping this theory in mind, the same thought process should hold true for a person who uses a manual wheelchair as their means of mobility. If it is exercise to propel the chair, then you can become exhausted before the day even begins. You might not be able to participate in certain activities or engage in your community if you are exhausted because you are constantly “exercising”. What happens over a period of time to the shoulders? Are the shoulders meant to be exercising this many hours a day?

Functional Mobility should not be exercise! Functional mobility is a right for all of us, no matter what form of mobility we use. Pushing a wheelchair can be exercise, like a brisk walk or jogging. But remember, not all able-bodied people choose this as their exercise. Also, the upper limbs are more vulnerable to injury than lower limbs so “pushing for exercise” needs to be done in a way that does not present a danger of upper limb injury.

So, am I saying that no one should be in a manual wheelchair? NO! Instead, what we need to do is consider the individual, their environment, and their goals. Many end-users are able to propel their manual wheelchairs throughout the day, but some end-users may be working too hard to complete this mobility. In this case, we need to consider other options to help the end-user preserve their shoulders, reach their goals, and maintain their independence. Next week we will discuss one of these options – Power Assist!

Per Udden, the founder of Permobil, said it best:
“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.”



Pneumatic Tyres Versus Solid Tyre: An End-Users Perspective



A critical part of a wheelchair, by definition, is the rear wheels and a critical part of the rear wheels is the type of tyre used. There are pros and cons for different tyre types. Rachel asked me to write about my experience with pneumatic and solid tyres, so here goes.

In my earlier years as a wheelchair user I used pneumatic tyres. One of the things that was a party spoiler was flat tyres. I had a bag that used to hang off the back of my chair, and it always had a spare tube and some tyre levers in it. But it was a hassle, for myself and my friends, and after a while I got sick of flat tyres. Plus, I had started travelling and just wanted the security and convenience of no flats. So, at some stage, I switched to solid tyres.



I rolled on solid tyres for a lot of years. I got used to them, and they worked well. They were hard work when I needed to change them, but I felt secure with them. I was playing wheelchair basketball at the time and was using high pressure pneumatic tyres on my sports chair. The difference in roll resistance was significant, but for everyday use I just preferred the security that solids gave me. Then, about 12 years ago, a range of puncture resistant tyres became available in Australia. They claimed to be able to resist punctures from thumb tacks, and a few of my friends were using them so I decided to give them a go.

When I changed to these pneumatic tyres and pushed my chair again it was like a new chair, it was so much easier to push! I was really shocked at the difference. Research that compares pneumatic and solid tyres confirms the significant difference in performance between the two.

One paper which supports this is “The ergonomics of different tyres and tyre pressure during wheelchair propulsion” by BONITA J. SAWATZKY and Co. in Nov 2004 which found that “Choosing solid tyres instead of pneumatics puts those using the wheelchair at potential risk. Pneumatic tyres showed no statistically significant difference in rolling resistance until pressures had decreased to 50% of the recommended value. The performance of the solid tyre was worse than that of the pneumatic tyres even when they were inflated at 25% of the recommended pressure.”

I have been using them ever since, and they have proved to be sufficiently puncture resistant for my use. Even though they are more expensive than non-puncture resistant tyres they have proven to be longer lasting which makes them a better economical option. I have had only one puncture in all the time I have used them. Being brutally honest with you, I am not the role model wheelchair user when it comes to doing maintenance. For maintenance on pneumatic tyres I have a rechargeable cordless compressor which I use regularly to make sure there is sufficient air in the tyres. Changing tubes and tyres is not on my list of things I want to do on any day, besides which I suck at it. I have pinched more tubes than I would care to mention. So, any new tyres/tubes I need are now supplied and fitted by my local bike shop. If you live close to a good wheelchair dealer, they should also be able to do this. In saying this, for a vast number of wheelchair users, changing a tube and tyre is a quick and easy process.

Depending on a wheelchair user’s environment and daily activities, puncture resistant tyres may not be required. In this case economical tyres might be a better solution.
On the other hand, some people will require more puncture-proof resistance than any pneumatic tyre can provide. For example, people living in rural areas that come into contact with “three cornered jacks” or working in environments where there are nails and the like. In these cases, the compromise in performance can be justified and solid tyres may be the best option. And, for a lot of users, the absolute confidence solid tyres give them is worth the loss in performance.


Some final thoughts, overall solid tyres are heavier than pneumatic tyres. There are different types of solid and pneumatic tyres and, in my experience, it has been worth spending a little more on good, quality tyres. The increased life of better-quality tyres usually means it is more economical in the long run. I would also not recommend solid inserts in pneumatic tyres. They are heavy and do not perform as well as other options.